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Based on interview, policy review, and incident reports, the hospital failed to review, investigate, and respond to a verbal grievance alleged by: a) family member " a " in the hospital's parking lot to S1CEO regarding frequent falls of Patient #4 on 06/04/12 for 1 of 1 grievance alleged as per policy, and b) family member "b" to S1CEO regarding patient falls and smoking against family wishes for Patient #4 on 06/05/12 at 11:45 a.m. for 1 of 1 grievances alleged at the hospital from January through June of 2012. Findings:

a) Family member "a":
In an interview conducted on 06/12/12 at 4:45 p.m. and at 4:50 p.m. with S1CEO, he indicated there was a verbal concern reported to him by family member "a" in the hospital's parking lot last Wednesday, 06/04/12 regarding the patient (#4) had fallen. The Chief Executive Officer, S1 denied knowledge of how many falls Patient #4 had during his hospital stay from 05/03/12 to 06/06/12. S1 reported family member "a" was not aware of how many falls Patient #4 had during his hospitalization. The CEO indicated the verbal complaint alleged from family member "b" regarding his concerns of a fall with Patient #4 on 06/04/12 was not a grievance rather it was a complaint. S1 further indicated he instructed family member "a" that he would bring his issue/concern the next morning, 06/05/12 at the multidisciplinary meeting. The CEO stated the grievance process was not initiated and/or followed regarding a concern that family member "a" had regarding Patient #4 falling. There was no review, investigation, and/or report initiated for the verbal concern alleged from family member "a" on 06/04/12. S1CEO indicated the verbal concern from family member "a" on 06/04/12 was not recorded as a grievance in the June Grievance Log.

Review of the "Grievance Log" for June of 2012 revealed there was no documented evidence a verbal concern/grievance was alleged from family member "a" on 06/04/12. There was no documentation S1CEO and/or S2DON reviewed, investigated and/or responded to the verbal grievance alleged to S1CEO on 06/04/12 as per policy.

b) family member "b""
Review of the "Grievance Logs" for June of 2012 revealed there was a complaint alleged from family member "b" regarding Patient #4's fall and smoking against family wishes to S1CEO on 06/05/12 with no time documented of when the complaint was filed from family member, "b". Further review of the June Grievance Log revealed the grievance from Patient #4's family member "b" was pending. Review of the "Complaint Notification" form dated/timed 06/05/12 at 11:45 a.m. read in part, "family member "b" (named) contacted CEO (S1) to discuss concerns regarding Patient #4. Family member "b" was upset because Patient #4 had recently fallen and suffered a cut/abrasion behind his ear. Family member "b" also complained that Patient #4 was allowed to smoke outside. The family member "b" wanted to know about the hospital's fall policies and what was done about Patient #4's incident. The family member, "b" claims that there was not enough done about it and that the staff was not responsive enough to his calls. The hospital have some people in the nursing department that communicated poorly. Family member, "b" said his family (#4) was important to him and that he needed better communication. The family member "b" left a list of family members with phone numbers to call. Family member "b" said others were called but he ("b") was not. The family member, "b" said he was not trying to start anything with us but he was very angry." Further review of the "Complaint Notification" form indicated the CEO, S1 promised family member "b" that he (S1) would put together a report that would summarize his (S1's) findings. No time table was established for its completion however S1CEO told family member "b" that he (S1) would be prompt. The CEO, S1 assured the family member "b" the facility had fall policies in place that are viewed on every patient as a fall risk. S1CEO did not have the chart to respond to his (family member "b's" concerns but promised to follow up. S1CEO explained that the rehab hospitals everywhere have patient falls that are all concerned with. The CEO, S1 informed family member "b" of one on one sitters were provided. A full assessment of the records as well as dialogue with staff will be conducted in preparation for the report.

Based on record reviews and staff interviews, the hospital failed to ensure the Grievance Process specified times frames for review, investigation, and response for each grievance alleged for 1 of 1 sampled patient as evidenced by failing to have specified time frames for the DON, S2 to review, investigate and respond to grievances alleged from a patient/family member in the "Patient/Family Grievance" policy (#4).

Findings:

Review of the policy titled, "Patient/Family Grievance", Policy No: I-A.1.11, issued date of 10/05, with no revised and/or reviewed dates, read in part, "...Emphasis is placed on the right to present a complaint or express a concern by verbally discussing the problem with any staff member including the DON, or Administrator and replying in written form. Upon receiving a verbal complaint, a complaint notification report form will be completed by the employee receiving the complaint, and will be referred to the appropriate supervisor. Complaints will be referred to the DON or Administrator in a timely manner, during working hours and be responded to. She/he will assist patients and families in the resolution of problems with hospital departments as they occur. The employee receiving the complaint routes complaints and/or responses to the appropriate supervisor who coordinates investigations or follow-ups, and provides feedback to patient and family member on resolution. Complaints made by the patient/family related to quality of care are referred to the Administrator, who will inform the patient/family that the complaint can be referred to an appropriate Utilization and PRO Organization. The DON shall follow up the complaint by investigating the complaint and developing a corrective plan of action. The DON will report the following through written communication (Investigative Report Form)...The completed Complaint Form and Investigative Report shall be submitted to the Director of Quality/Risk Management for tracking and trending. Any unresolved issues will be brought to the attention of Administration. Any complaints involving patient injure will be submitted to the Administrator. Grievances will be discussed in the Safety and Risk Committee Meetings. The findings shall also be submitted to the Governing Board as part of the PI Function Report. The Hospital will supply the patient with a written response to their grievance, by the Administrator or DON...".

Record review of the form titled "Complaint Notification" dated 6/5/12 at 11:45 a.m. by S1CEO, under "Document any Actions Taken" revealed S1CEO had "promised family member "b" that he would put together a report that would summarize my (S1CEO) findings. No time table was established for its completion, however I (S1CEO) told him that I would be prompt....A full assessment of the records as well as dialogue with staff will be conducted in preparation for the report..."

In an interview conducted on 06/12/12 at 4:45 p.m. and at 4:50 p.m. with S1CEO, he confirmed there was a complaint alleged from family member "b" for Patient #4 on 06/05/12.
As of 6/14/12, S1CEO had not communicated with family member "b" either by telephone or in a written letter.

Further review of the "Grievance" Policy revealed there was no documentation of a time frame in which the patient/family members are informed of the outcome of the complaint or the hospital is still working to resolve the grievance.

Based on interview, record review, and policy review, the hospital failed to (1) identify forms of abuse, specifically neglect, failed to investigate the neglect, and report these allegations to DHH in accordance with the 24-hour reporting time frame (Louisiana Revised Statutes Title 40. Public Health and Safety Chapter 11. State Department of Health and Hospitals ? 2009.2.) as evidenced by Patient #4 experiencing 6 falls, 3 of which were unwitnessed resulting in a laceration behind the right ear after the fall on 5/25/12 and a possible hematoma on the right back area after the fall on 6/3/12; and (2) failing to provide services (neglect) to prevent falls as evidenced by failing to follow physician's orders of not leaving Patient #4 unattended or Patient #4 must be in view at all times. Findings:
(1) Failing to identify forms of abuse, specifically neglect, failed to investigate the neglect, and report these allegations to DHH in accordance with the 24-hour reporting time frame (Louisiana Revised Statutes Title 40. Public Health and Safety Chapter 11. State Department of Health and Hospitals ? 2009.2)

Review of form titled "Patient Rights and Ownership Notification" #17 noted all patients have "the right to be free from all forms of abuse and harassment."

Review of Policy No:I-A.1.24.1 titled "Elder Abuse", issued 10/05 under Policy (pg 1 of 3) reveals "Any person, who, in the scope of employment at the hospital or in his professional capacity, has knowledge of or reasonable cause to believe that any patient has been the victim of abuse or exploitation has an obligation to report such abuse, first to his supervisor or department manager. LARS (Louisiana Register Statute) 14.403.2 requires the reporting of abuse and exploitation of patients and residents of patient care facilities, established criminal penalties for abuse and for failure to report and prohibits retaliation against individuals who report such incidents. The Social Services Director, CEO along with the hospital attorney, will be responsible to insure that such reports are transmitted to the appropriate state authority and is designated as the official hospital representative in terms of communications sent to or received from the state." Under Signs and Symptoms of Elderly Abuse, (pg 2 of 3), the policy noted that physically (physical) injury was a sign of abuse. On Pg 3 of 3, the policy noted "There may be other signs and symptoms of elderly abuse, and not all of those listed by them indicate mistreatment, neglect, or abuse. However, if any seem to increase in number or severity, it may be an indication of abuse."

Patient #4, 46 year old male, was admitted to the hospital on 5/9/12. Reasons for Rehab include: (1) Stroke involving left temporal, occipital, and periventricular parietal lobe resulting in Right sided paralysis (2) Old fracture involving right hand; (3) Hypertension; and (4) Morbid obesity. According to S7 MD's History and Physical and Preadmission Evaluation (pg 3 of 6), Patient #4 had significant aphasia. He was answering questions, but the answers were inappropriate. On Page 4 of 6, under Diagnosis, S7 MD documented Patient #4 had an acute nonhemorrhagic stroke of the left lob; aphasia; visual loss particularly involving the lateral upper and lower visual fields; and right hemiparesis (paralysis) with the right arm worse than the right leg. Patient #4 also has unstable hypertension. S7 MD's plan of care (pg 5 of 6) included: "Physical Therapy: To work on fine motor control, strengthening, bed mobility, transfer training and progressive gait....the patient is unsafe. We need to focus on fall prevention as well. Occupational Therapy: Upper and lower extremity dressing and strengthening particularly the right upper extremity. The patient will need to be assisted with grooming and feeding because of his aphasia, visual fields cuts and weakness.... Speech: For cognitive, swallowing and speech remediation. Nursing: For careful monitoring of blood pressure....Also will start patient on bowel and bladder training and pain control because of his arthritis....Prognosis: Prognosis is good. Goals (pg 6 of 6): Goals are supervision with bed mobility, transfer training. Minimal assist with upper and lower extremity dressing. Minimal/moderate with lower extremity bathing and functional transfers."

Record review of the Fall Incident Report dated 5/11/12 revealed Patient #4 was found on the floor at 1650 (4:50 p.m.). Under "Description of Event, including any obvious fall related injuries and describe what the patient was doing or trying to do that may have contributed to the fall:" revealed Patient #4 was attempting to get out of bed and fell before getting into wheelchair." Under "Fall witnessed" a check mark indicated a response of "No" indicating the fall was not witnessed. Under "Orders given," revealed ATC 1:1 sitter.

Record review of Physician's Orders dated 5/14/12 at 1230 (12:30 p.m.), S7 MD discontinued the 1:1 sitters. S7 MD ordered "Staff to check on patient every hour."

Record review of the Fall Incident Report dated 5/16/12 revealed Patient #4 was found on the floor at 0930 (9:30 a.m.) and the fall was unwitnessed. Under "Description of Event", S4 LPN documented she found patient on floor in a sitting position next to laptray. S4 LPN assisted Patient #4 into the wheel chair and then attempted to roll patient to the front of the nurse's station when the patient became combative. Patient #4 was placed in the doorway of his room for staff to observe until therapy arrived. Under "Orders given:" S4 LPN documented the physician had ordered "Do not leave patient unattended."

Record review of Physician's Orders dated 5/16/12 noted Patient #4 was not to be left unattended.

Record review of the Fall Incident Report dated 5/18/12 at 07:30 a.m., Patient #4 had a witnessed fall. According to the Fall Incident Report, S6 LPN documented Patient #4 was taking a shower, bent over to take the dressing off shin and he fell over onto the floor. Under Orders given, S6 LPN documented "Monitor patient closely, do not leave patient unattended." This fall was witnessed by S9 CNA.

(2) Failed to provide services (neglect) to prevent falls as evidenced by failing to follow physician's orders of not leaving Patient #4 unattended or Patient #4 must be in view at all times.

On 6/13/12 at 2:30 p.m. in a face-to-face interview with S4 LPN, she confirmed on 5/18/12, S7 MD did not order any new interventions after patient #4 had fallen. Patient #4 was not to be left alone unattended from 5/16/12 - 5/25/12.

Record review of the Fall Incident Report dated 5/24/12 revealed Patient #4 had called for assistance to the bathroom at 21:10 (9:10 p.m.). When S6 LPN went into patient's room, she told him to wait while she obtained a wheelchair. S6 documented Patient #4 argued he wanted to get up and walk to the bathroom. S6 LPN documented she was getting the wheelchair on the right side of the bed when patient began trying to get up on the left side of the bed when he fell on his bottom. Physician was notified on 5/25/12 at 04:20 a.m.

Record review of Fall Incident Report dated 5/25/12 revealed Patient #4 was found on the floor on the back patio at 1300 (1:00 p.m.). According to S4 LPN she documented "family members outside alerted staff that patient was on the ground outside. Patient was found sitting upright next to the wheelchair. The lap tray and seat belt were taken off or not in use when found. Assisted patient back to the wheelchair and brought the patient back to his room." During the assessment, S4 LPN discovered a laceration to the posterior of the right ear noted. She cleaned and bandaged area. Physician and family member notified.

Record review of Wound/Incision form dated 5/25/12 and signed by S4 LPN revealed the injury was located on the right posterior ear. There were no staples, wound bed color was documented as "pinched", and "Tenderness" was circled. There was also a color photograph of the injury in the clinical record.

Record review of Physician's Orders dated 5/25/12 revealed an order for 1:1 sitters, Neuro checks every 6 hours x 12 hours; if normal, then D/C (discontinue) Neuro checks.

Record review of Physician's Orders dated 5/30/12 revealed an order to D/C (discontinue) 1:1 sitter; Staff is to not allow patient (#4) to be out of their site during the day; Head CT scan.

Record review of the CT (Computerized Tomography) Brain without Contrast Report Form dated 5/30/12 and signed 2:51 p.m. revealed no hemorrhages, no midline shift, and no atrophy seen.

Record review of the Fall Incident Report dated 6/3/12 revealed Patient #4 was attempting to stand up to get some coffee in the dining room. Staff from across the dining room witnessed Patient #4 fall onto the floor landing on his right side.

Record review of Physician's Orders dated 6/3/12 at 1930 (7:30 p.m.) revealed another order for 1:1 sitters. Physician's Orders dated 6/5/12 at 1515 (3:15 p.m.) revealed "Ok for family to stay with patient 24 hours/day."

Record review of Radiology Report dated 6/5/12 at 17:03 (5:03 p.m.) revealed the results of the right-sided abdomen ultrasound. The results indicated "a palpable soft tissue mass in the right upper quadrant, which has the appearance of an abdominal wall lesion...Etiology is not apparent, but possibilities include abdominal wall hematoma, lipoma or possible muscle lesion such as leiomyoma."

On 6/12/12 at 11:30 a.m. in a face-to-face interview with S2 DON, she stated patients' falls are reported to the physician the next morning if there was no injuries. If the patient received an injury or incidence of trauma occurred, then the physician is notified regardless of the time of day or night. S2 verified if physician orders "Do not leave patient unattended" then, the hospital is to increase supervision of patient with current staff. She explained the RNs and CNAs would take turns checking on patient. If the physician orders to "Not to let patient out of sight", S2 DON stated it was the same thing as not leaving patient unattended. She verified staff should be in the room at all times. S2 also verified the hospital did not have an observational policy in place to guide the nurses.

On 6/13/12 at 2:00 p.m. in a face-to-face interview with S10 CNA/Tech, she stated the RN gives the CNAs patient assignments. S10 confirmed on 5/25/12, she provided care for Patient #4 at 1500 (1:00 p.m.), 1700 (5:00 p.m.), and 1900 (7:00 p.m.). She stated she had assisted Patient #4 with a Bowel movement at 1500 (1:00 p.m.). She stated she was asked to come in early. She received report from the outgoing CNA (S9) who had reported that Patient #4 had fallen. S10 CNA/Tech denied she was with patient #4 when he fell and she had not taken patient #4 outside to the back yard patio.

On 6/13/12 at 2:30 p.m. in a face-to-face interview with S4 LPN stated if the physician orders to "not leave patient unattended," then the staff are to notify the charge nurse of the date the physician ordered. She stated the charge nurse on the prior shift makes patient assignments to ensure tasks are completed. S4 LPN confirmed she was with Patient #4 on 5/25/12. When she read the orders by the physician to "Not let the patient out of site, she interpreted it to mean the staff nurses were to check on patient #4 at least every hour. When the orders were written at 1500 (3:00 p.m.), she sent a copy to S11 ADON. The Unit Secretary gave a copy to the charge nurse on duty.

During this same interview with S4 LPN, she verified Patient #4 was outside without staff among other patient's family members attempting to smoke. She stated he had wheeled himself outside. S4 LPN confirmed there was no staff member on the outside with Patient #4. She verified that no staff had gone outside with Patient #4 and no one observed him fall. After a private sitter for another patient had alerted her of Patient #4 falling, she stated she went outside to help patient get back into the wheelchair. S4 confirmed it was when she was "checking the patient over" that she discovered the laceration behind the ear. S4 stated she cleaned the wound and dressed it with clean gauze.

S4LPN stated on 6/3/12, Patient #4 had fallen again in the dining room. She stated S7 MD had reordered 1:1 sitters at 7:30 p.m. S4 LPN stated patient #4 had 1:1 sitters until 6/6/12 until he was discharged. She stated S7 MD had ordered patient needs 24 hour supervision when he returns home because his was a Fall risk.

On 6/13/12 at 3:15 p.m. in a face-to-face interview with S9 CNA/Tech, she stated she assisted S12 CNA with Patient #4 with his Bowel/Bladder training program. When asked if the physician wants a patient to be on 1:1, S9 stated it means total patient care, staying with the patient at all times. If the physician orders "not to leave patient unattended" or "to keep patient in sight at all times", S9 CNA stated someone needs to be with the patient at all times. S9 CNA stated they do not document in the chart when they have to sit with patients on a 1:1. S9CNA confirmed she was with Patient #4 on 5/25/12 from 1:00 p.m. to 2:00 p.m. She denied she brought Patient #4 outside. S9 stated when she brings a patient outside, she stays with the patient.

On 6/14/12 at 10:00 a.m. in a telephone interview with S7 MD, Medical Director, she confirmed she orders 1:1 sitters when patients fall. When she discontinues 1:1 sitters, but orders the patient "Not to be left unattended", S7 MD stated she expects someone to assume responsibility for the patient. S7 stated it could be the nurse assigned to the patient or the CNA assigned to the patient. S7 MD stated she expects the nursing staff to be by the patient at all times. When she orders a patient "Not to be out of eyesight," S7 MD stated she expects nursing staff to keep the patient in view at all times. S7 MD stated she expected the nursing staff to know what she means when she writes orders, such as "1:1 sitter", "do not leave patient unattended," or "patient not to be out of sight." S7 stated she knows the night shift understands what she means when she rights these orders, but she is not sure about the day shift. S7 MD stated family members can be with a patient in preparation for the Transitional Living Arrangements (TLA). She stated she encourages some family members to stay with the patient because it helps them to adjust to the changes they will be facing when the patient leaves the hospital. S7 MD added that when she scheduled a family conference with Patient #4's family, only one family member was present.
Review of LA R.S. 40. ?2009.2 revealed:
Louisiana Revised Statutes Title 40. Public Health and Safety Chapter 11. State Department of Health and Hospitals ?2009.2 A. Defines the following terms (1) "Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. (2) "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. B. (1) Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four (24) hours, submit a report to the department (DHH) or inform the unit or local law enforcement agency of such abuse or neglect...

Based on interview, clinical record review, and Fall Incident Reports, the hospital failed to ensure patient safety for 1 of 5 patients as evidenced by not following physician's orders of not leaving Patient #4 unattended or out of line of sight, which resulted in Patient #4 wheeling himself out of the facility where he experienced a fall, lacerating an area behind his right ear. Findings:

Record review of the Fall Incident Report dated 5/11/12 revealed Patient #4 was found on the floor at 1650 (4:50 p.m.). Under "Description of Event, including any obvious fall related injuries and describe what the patient was doing or trying to do that may have contributed to the fall:" revealed Patient #4 was attempting to get out of bed and fell before getting into wheelchair." Under "Fall witnessed" a check mark indicated a response of "No" indicating the fall was not witnessed. Under "Orders given," revealed ATC 1:1 sitter.

Record review of Physician's Orders dated 5/14/12 at 1230 (12:30 p.m.), S7 MD discontinued the 1:1 sitters. S7 MD ordered "Staff to check on patient every hour."

Record review of the Fall Incident Report dated 5/16/12 revealed Patient #4 was found on the floor at 0930 (9:30 a.m.) and the fall was unwitnessed. Under "Description of Event", S4 LPN documented she found patient on floor in a sitting position next to laptray. S4 LPN assisted Patient #4 into the wheel chair and then attempted to roll patient to the front of the nurse's station when the patient became combative. Patient #4 was placed in the doorway of his room for staff to observe until therapy arrived. Under "Orders given:" S4 LPN documented the physician had ordered "Do not leave patient unattended."

Record review of Physician's Orders dated 5/16/12 noted Patient #4 was not to be left unattended.

Record review of the Fall Incident Report dated 5/18/12 at 07:30 a.m., Patient #4 had a witnessed fall. According to the Fall Incident Report, S6 LPN documented Patient #4 was taking a shower, bent over to take the dressing off shin and he fell over onto the floor. Under Orders given, S6 LPN documented "Monitor patient closely, do not leave patient unattended." This fall was witnessed by S9 CNA.

On 6/12/12 at 10:40 a.m. in a face-to-face interview with S8 RN, she stated if a patient asks to go smoke, then they assess the patient's safety level before allowing the patient to go out by themselves. If the patients cannot go out by themselves, the patients must allow a nurse or tech/CNA to accompany the patient. S8 RN stated to her knowledge, this was required for patient safety.

During this same interview, S8 RN stated if a patient falls and receives an injury, the nursing staff provides the medical care needed, the family member is notified, the doctor is notified, the incident is documented in nurse's notes, an incident report is filled out and then the incident report is placed in the DON's box. The nursing staff then updates the care plan with new interventions.

On 6/13/12 at 2:30 p.m. in a face-to-face interview with S4 LPN, she confirmed on 5/18/12, S7 MD did not order any new interventions after patient #4 had fallen. Patient #4 was not to be left alone unattended from 5/16/12 - 5/25/12.

Record review of the Fall Incident Report dated 5/24/12 revealed Patient #4 had called for assistance to the bathroom at 21:10 (9:10 p.m.). When S6 LPN went into patient's room, she told him to wait while she obtained a wheelchair. S6 documented Patient #4 argued he wanted to get up and walk to the bathroom. S6 LPN documented she was getting the wheelchair on the right side of the bed when patient began trying to get up on the left side of the bed when he fell on his bottom. Physician was notified on 5/25/12 at 04:20 a.m.

Record review of Fall Incident Report dated 5/25/12 revealed Patient #4 was found on the floor on the back patio at 1300 (1:00 p.m.). According to S4 LPN she documented "family members outside alerted staff that patient was on the ground outside. Patient was found sitting upright next to the wheelchair. The lap tray and seat belt were taken off or not in use when found. Assisted patient back to the wheelchair and brought the patient back to his room." During the assessment, S4 LPN discovered a laceration to the posterior of the right ear noted. She cleaned and bandaged area. Physician and family member notified. There were no nursing staff or tech/CNA with the patient outside on the patio.

Record review of Wound/Incision form dated 5/25/12 and signed by S4 LPN revealed the injury was located on the right posterior ear. There were no staples, wound bed color was documented as "pinched", and "Tenderness" was circled. There was also a color photograph of the injury in the clinical record.

Record review of Physician's Orders dated 5/25/12 revealed an order for 1:1 sitters, Neuro checks every 6 hours x 12 hours; if normal, then D/C (discontinue) Neuro checks.

Record review of Physician's Orders dated 5/30/12 revealed an order to D/C (discontinue) 1:1 sitter; Staff is to not allow patient (#4) to be out of their site during the day; Head CT scan.

Record review of the CT (Computerized Tomography) Brain without Contrast Report Form dated 5/30/12 and signed 2:51 p.m. revealed no hemorrhages, no midline shift, and no atrophy seen.

Record review of the Fall Incident Report dated 6/3/12 revealed Patient #4 was attempting to stand up to get some coffee in the dining room. Staff from across the dining room witnessed Patient #4 fall onto the floor landing on his right side.

Record review of Physician's Orders dated 6/3/12 at 1930 (7:30 p.m.) revealed another order for 1:1 sitters. Physician's Orders dated 6/5/12 at 1515 (3:15 p.m.) revealed "Ok for family to stay with patient 24 hours/day."

Record review of Radiology Report dated 6/5/12 at 17:03 (5:03 p.m.) revealed the results of the right-sided abdomen ultrasound. The results indicated "a palpable soft tissue mass in the right upper quadrant, which has the appearance of an abdominal wall lesion...Etiology is not apparent, but possibilities include abdominal wall hematoma, lipoma or possible muscle lesion such as leiomyoma."

On 6/12/12 at 11:30 a.m. in a face-to-face interview with S2 DON, she stated patients' falls are reported to the physician the next morning if there was no injuries. If the patient received an injury or incidence of trauma occurred, then the physician is notified regardless of the time of day or night. S2 verified if physician orders "Do not leave patient unattended" then, the hospital is to increase supervision of patient with current staff. She explained the RNs and CNAs would take turns checking on patient. If the physician orders to "Not to let patient out of sight", S2 DON stated it was the same thing as not leaving patient unattended. She verified staff should be in the room at all times. S2 also verified the hospital did not have an observational policy in place to guide the nurses.

On 6/13/12 at 2:00 p.m. in a face-to-face interview with S10 CNA/Tech, she stated the RN gives the CNAs patient assignments. S10 confirmed on 5/25/12, she provided care for Patient #4 at 1500 (1:00 p.m.), 1700 (5:00 p.m.), and 1900 (7:00 p.m.). She stated she had assisted Patient #4 with a Bowel movement at 1500 (1:00 p.m.). She stated she was asked to come in early. She received report from the outgoing CNA (S9) who had reported that Patient #4 had fallen. S10 CNA/Tech denied she was with patient #4 when he fell and she had not taken patient #4 outside to the back yard patio.

On 6/13/12 at 2:30 p.m. in a face-to-face interview with S4 LPN stated if the physician orders to "not leave patient unattended," then the staff are to notify the charge nurse of the date the physician ordered. She stated the charge nurse on the prior shift makes patient assignments to ensure tasks are completed. S4 LPN confirmed she was with Patient #4 on 5/25/12. When she read the orders by the physician to "Not let the patient out of site, she interpreted it to mean the staff nurses were to check on patient #4 at least every hour. When the orders were written at 1500 (3:00 p.m.), she sent a copy to S11 ADON. The Unit Secretary gave a copy to the charge nurse on duty.

During this same interview with S4 LPN, she verified Patient #4 was outside without staff among other patient's family members attempting to smoke. She stated he had wheeled himself outside. S4 LPN confirmed there was no staff member on the outside with Patient #4. She verified that no staff had gone outside with Patient #4 and no one observed him fall. After a private sitter for another patient had alerted her of Patient #4 falling, she stated she went outside to help patient get back into the wheelchair. S4 confirmed it was when she was "checking the patient over" that she discovered the laceration behind the ear. S4 stated she cleaned the wound and dressed it with clean gauze.

S4LPN stated on 6/3/12, Patient #4 had fallen again in the dining room. She stated S7 MD had reordered 1:1 sitters at 7:30 p.m. S4 LPN stated patient #4 had 1:1 sitters until 6/6/12 until he was discharged. She stated S7 MD had ordered patient needs 24 hour supervision when he returns home because his was a Fall risk.

On 6/13/12 at 3:15 p.m. in a face-to-face interview with S9 CNA/Tech, she stated she assisted S12 CNA with Patient #4 with his Bowel/Bladder training program. When asked if the physician wants a patient to be on 1:1, S9 stated it means total patient care, staying with the patient at all times. If the physician orders "not to leave patient unattended" or "to keep patient in sight at all times", S9 CNA stated someone needs to be with the patient at all times. S9 CNA stated they do not document in the chart when they have to sit with patients on a 1:1. S9CNA confirmed she was with Patient #4 on 5/25/12 from 1:00 p.m. to 2:00 p.m. She denied she brought Patient #4 outside. S9 stated when she brings a patient outside, she stays with the patient.

On 6/14/12 at 10:00 a.m. in a telephone interview with S7 MD, Medical Director, she confirmed she orders 1:1 sitters when patients fall. When she discontinues 1:1 sitters, but orders the patient "Not to be left unattended", S7 MD stated she expects someone to assume responsibility for the patient. S7 stated it could be the nurse assigned to the patient or the CNA assigned to the patient. S7 MD stated she expects the nursing staff to be by the patient at all times. When she orders a patient "Not to be out of eyesight," S7 MD stated she expects nursing staff to keep the patient in view at all times. S7 MD stated she expected the nursing staff to know what she means when she writes orders, such as "1:1 sitter", "do not leave patient unattended," or "patient not to be out of sight." S7 stated she knows the night shift understands what she means when she rights these orders, but she is not sure about the day shift.

Record review of Policy # No.: I-E.5.00 titled "Organizational Performance Improvement Plan" (pg 3 of 17) revealed the organization's responsibility: "Necessary information is communicated among department/services when problems or opportunities to improve patient care involve more than one department/service....Important key aspects and processes of care to the health and safety of patients are identified. Included are those that occur frequently or affect large numbers of patients; place patients at risk of serious consequences of deprivation of substantial benefit if care is not provided correctly or not provided when indicated; or care provided is not indicated, those tending to produce problems for patients, their families or staff, and those that may lead to sentinel events."

The hospital failed to follow their policies and procedures of improving organizational performance when the nursing staff failed to follow physician's orders of not leaving Patient #4 unattended and the patient wheeled himself outside to the back patio, which resulted in a fall and injuring himself by lacerating an area behind his right ear. The hospital failed to follow their policies and procedures of improving organizational performance by the night shift not communicating with the day shift about the intent of the physician's orders of not leaving the patient unattended.

Based on interview and policy review, the hospital (1) failed to schedule patient assignments to ensure patient safety for 1 of 5 sampled patients as evidenced by not assigning specific staff to be responsible for Patient #4 when the physician ordered patient not to be left unattended, which resulted in Patient #4 wheeling himself out of the building, falling, and experiencing a laceration in the back of his right ear. Findings:

Record review of the Fall Incident Report dated 5/16/12 revealed Patient #4 was found on the floor at 0930 (9:30 a.m.) and the fall was unwitnessed. Under "Description of Event", S4 LPN documented she found patient on floor in a sitting position next to laptray. S4 LPN assisted Patient #4 into the wheel chair and then attempted to roll patient to the front of the nurse's station when the patient became combative. Patient #4 was placed in the doorway of his room for staff to observe until therapy arrived. Under "Orders given:" S4 LPN documented the physician had ordered "Do not leave patient unattended."

On 6/13/12 at 2:30 p.m. in a face-to-face interview with S4 LPN, she confirmed on 5/18/12, S7 MD did not order any new interventions after Patient #4 had fallen. Patient #4 was not to be left alone or unattended from 5/16/12 - 5/25/12. S4 LPN added this order was difficult to follow because of the staffing schedule and workload of being responsible for the care of 6 to 7 patients.

Record review of the Nursing Department Daily Assignment Sheet dated 5/16/12 for the 7a-3p shift revealed S4 LPN was assigned a total of 6 patients, which included Patient #4. The CNA Assignment revealed 1 CNA was assigned a total of 6 patients, which included Patient #4. On the 3p-11p shift, there was 1 staff nurse assigned a total of 6 patients, which included Patient #4 up to 7 p.;then the next staff nurse from 7p-7a was assigned the same patients. The CNA Assignment revealed 1 CNA scheduled for the 3p-11p shift was assigned a total of 7 patients, which included Patient #4. On 11p-7a, one (1) CNA was assigned a total of 9 patients, which included Patient #4.

Record review of the Nursing Department Daily Assignment Sheet dated 5/17/12 7a-3p shift revealed S8 RN was assigned a total of 6 patients, which included Patient #4. The CNA Assignment revealed S9 CNA was assigned a total of 7 patients, which included Patient #4. On the 3p-11p shift, S8 RN was assigned an additional patient. The CNA Assignment revealed S10 CNA was assigned a total of 8 patients, which included Patient #4. There was an extra CNA for the hospital scheduled 4 p-10 p. On the 11p-7a shift, the nursing staff was assigned a total of 7 patients, which included Patient #4. One (1) CNA was assigned a total of 12 patients, which included Patient #4.

Record review of the Nursing Department Daily Assignment Sheet dated 5/18/12 7a-3p shift revealed one (1) nursing staff assigned to a total of 6 patients, which included Patient #4. On the CNA Assignment, S9 CNA was assigned a total of 8 patients, which included Patient #4. On the 3p-11p shift, the nursing staff was assigned a total of 7 patients, which included Patient #4.The CNA Assignment revealed one (1) CNA was assigned a total of 8 patients, which included Patient #4. On the 11p-7a shift, one (1) CNA was assigned a total of 12 patients, which included Patient #4.

Record review of the Nursing Department Daily Assignment Sheet dated 5/19/12 7a-7p shift revealed one (1) nursing staff assigned a total of 6 patients, which included Patient #4.The CNA Assignment revealed one (1) CNA was assigned to a total of 12 patients, which included Patient #4. On the 7p-7p, nursing staff was assigned a total of 7 patients, which included Patient #4. The CNA Assignment revealed one (1) CNA was assigned a total of 12 patients, which included Patient #4.

Record review of the Nursing Department Daily Assignment Sheet dated 5/20/12 7a-7p shift revealed one (1) nursing staff was assigned a total of 5 patients, which included Patient #4. to On the CNA Assignment, one (1) CNA was assigned a total of 7 patients, which included Patient #4. On the 7p-7a shift, there was one (1) LPN assigned to a total of 7 patients, which included Patient #4. The CNA Assignments revealed one (1) CNA was assigned a total of 11 patients, which included Patient #4.

Record review of the Nursing Department Daily Assignment Sheet dated 5/21/12 7a-3p revealed S4 LPN assigned to a total of 6 patients, which included Patient #4. One CNA was assigned a total of 7 patients, which included Patient #4. On 3p-11p shift, S4 LPN was assigned a total of 7 patients, which included Patient #4. The CNA Assignment revealed S10 CNA was assigned a total of 7 patients, which included Patient #4. On 11p-7a shift, S6 LPN was assigned a total of 7 patients, which included Patient #4. One (1) CNA was assigned a total of 12 patients, which included Patient #4.

Record review of the Nursing Department Daily Assignment Sheet dated 5/22/12 7a-3p revealed S4 LPN was assigned a total of 6 patients, which included Patient #4.The CNA Assignment revealed one (1) CNA was assigned a total of 8 patients, which included Patient #4. On the 3p-11p shift, S3 LPN was assigned a total of 7 patients, which included Patient #4.The CNA Assignment revealed one (1) CNA was assigned to a total of 8 patients, which included Patient #4. On the 11p-7a shift, one (1) nursing staff member was assigned a total of 7 patients, which included Patient #7; one (1) CNA was assigned a total of 12 patients, which included Patient #4.

Record review of the Nursing Department Daily Assignment Sheet dated 5/23/12 7a-3p revealed one RN staff assigned to a total of 6 patients, which included Patient #4.The CNA Assignment revealed one (1) CNA assigned to a total of 8 patients, which included Patient #4. On 3p-11p shift, one (1) RN staff was assigned a total number of 7 patients, which included Patient #4; one (1) CNA was assigned a total of 9 patients, which included Patient #4. On 11-7 shift, S6 LPN was assigned a total of 6 patients, which included Patient #4; one (1) CNA was assigned a total of 11 patients, which included Patient #4.

Record review of the Nursing Department Daily Assignment Sheet dated 5/24/12 7a-3p revealed S4 LPN was assigned a total of 5 patients, which included Patient #4, as well as helping with ADLs (Activities for Daily Living). The CNA Assignment revealed one (1) CNA was assigned a total of 8 patients, which included Patient #4. On the 3p-11p shift, S6 LPN was assigned to a total of 6 patients, which included Patient #4, as well as helping with ADLs. One (1) CNA was assigned a total of 9 patients, which included Patient #4. On 11p-7a shift, one (1) CNA was assigned a total of 14 patients, which included Patient #4, as well as helping with ADLs. There were a total of 29 patients in the hospital.

Record review of the Fall Incident Report dated 5/24/12 revealed Patient #4 had called for assistance to the bathroom at 21:10 (9:10 p.m.). When S6 LPN went into patient's room, she told him to wait while she obtained a wheelchair. S6 documented Patient #4 argued he wanted to get up and walk to the bathroom. S6 LPN documented she was getting the wheelchair on the right side of the bed when patient began trying to get up on the left side of the bed when he fell on his bottom. Physician was notified on 5/25/12 at 04:20 a.m. The Fall Incident Report had no documentation of which staff was present in the patient's room.

Record review of the Nursing Department Daily Assignment Sheet dated 5/25/12 7a-3p shift revealed S4 LPN was assigned a total of 5 patients, which included Patient #4, as well as assisting with ADLs. The CNA Assignment revealed one (1) CNA assigned to a total of 8 patients, which included Patient #4. On 3p-11p, S3 LPN was assigned a total of 6 patients, which included Patient #4, as well as assisting with ADLs; one (1) CNA S10 CNA was scheduled to sit with patients in Room 119 A & B, because both had a physician's order for 1:1 sitters.

Record review of Fall Incident Report dated 5/25/12 revealed Patient #4 was found on the floor on the back patio at 1300 (1:00 p.m.). According to S4 LPN she documented "family members outside alerted staff that patient was on the ground outside. Patient was found sitting upright next to the wheelchair. The lap tray and seat belt were taken off or not in use when found. Assisted patient back to the wheelchair and brought the patient back to his room." During the assessment, S4 LPN discovered a laceration to the posterior of the right ear noted. She cleaned and bandaged area. Physician and family member notified.

Record review of Physician's Orders dated 5/30/12 revealed an order to D/C (discontinue) 1:1 sitter; Staff is to not allow patient (#4) to be out of their site during the day; Head CT scan.

Record review of Nursing Department Daily Assignment Sheet dated 5/31/12 7a-3p shift revealed S8RN was assigned to patients in Rooms 104, 107A, 108A, 108B, 119A, 123 for a total of 6 patients. The CNA Assignment schedule revealed S9 CNA was assigned to patients in Rooms 113-119A for a total of 5 patients. On 3p-11p shift, S4 LPN was assigned to patients in Rooms 103, 110, 111, 113, 115, 119A for a total of 6 patients as well as assisting with ADLs; one (1) CNA was assigned to patients in Rooms 119A-124 for a total of 8 patients.

Record review of Nursing Department Daily Assignment Sheet dated 6/1/12 7a-3p shift revealed S8RN was assigned patients in Rooms 104, 107A, 119A, 120B for a total of 4 patients; CNA Assignment revealed one (1) CNA assigned to patients in Rooms 119A-124 for a total of 8 patients. On 3p-11p shift, one (1) nursing staff member was assigned to patients in Rooms 103, 106A, 110, 111, 113, 119A for a total of 6 patients as well as being assigned to assist with ADLs; one (1) CNA was assigned to patients in Rooms 119A-124 for a total of 8 patients. On 11p-7a shift, one (1) LPN was assigned patients in Rooms 103, 106A, 110, 111, 113, 119A for a total of 6 patients as well as being assigned to assist with ADLs; one (1) CNA was assigned patients in Rooms 113-124 for a total of 13 patients.

Record review of Nursing Department Daily Assignment Sheet dated 6/2/12 7a-7p shift revealed one RN assigned to patients in Rooms 107A, 117A, 118A, 119A, 120B for a total of 5 patients; one CNA was assigned to patients in Rooms 119-124 for a total of 8 patients. On 7p-7a, one RN was assigned patients in Rooms 106B, 107A, 109, 117A, 118A, 119A for a total of 6 patients; one (1) CNA was assigned patients in Rooms 113-124 for a total of 14 patients. There were a total of 31 patients in the hospital.

Record review of Nursing Department Daily Assignment Sheet dated 6/3/12 7a-7p shift revealed one (1) nursing staff was assigned to Rooms 102, 105B, 108B, 119B, 121, 122, 119A until 3p for a total of 7 patients; one (1) CNA was assigned to Rooms 119-124 for a total of 7 patients. On the 7p-7a shift, one (1) nurse was assigned to patients in Rooms 106B, 107A, 109, 117A, 118A, 119A, 120B for a total of 7 patients; one (1) CNA was assigned to Rooms 113-124 for a total of 12 patients.

On 6/12/12 at 11:30 a.m. in a face-to-face interview with S2 DON, she stated patients' falls are reported to the physician the next morning if there was no injuries. If the patient received an injury or incidence of trauma occurred, then the physician is notified regardless of the time of day or night. S2 verified if physician orders "Do not leave patient unattended" then, the hospital is to increase supervision of patient with current staff. She explained the RNs and CNAs would take turns checking on patient. If the physician orders to "Not to let patient out of sight", S2 DON stated it was the same thing as not leaving patient unattended. She verified staff should be in the room at all times. S2 also verified the hospital did not have an observational policy in place to guide the nurses.

On 6/13/12 at 2:00 p.m. in a face-to-face interview with S10 CNA/Tech, she stated the RN gives the CNAs patient assignments. S10 confirmed on 5/25/12, she provided care for Patient #4 at 1500 (1:00 p.m.), 1700 (5:00 p.m.), and 1900 (7:00 p.m.). She stated she had assisted Patient #4 with a Bowel movement at 1500 (1:00 p.m.). She stated she was asked to come in early. She received report from the outgoing CNA (S9) who had reported that Patient #4 had fallen. S10 CNA/Tech denied she was with patient #4 when he fell and she had not taken patient #4 outside to the back yard patio.

On 6/13/12 at 2:30 p.m. in a face-to-face interview with S4 LPN stated if the physician orders to "not leave patient unattended," then the staff are to notify the charge nurse of the date the physician ordered. She stated the charge nurse on the prior shift makes patient assignments to ensure tasks are completed. S4 LPN confirmed she was with Patient #4 on 5/25/12. When she read the orders by the physician to "Not let the patient out of site, she interpreted it to mean the staff nurses were to check on patient #4 at least every hour. When the orders were written at 1500 (3:00 p.m.), she sent a copy to S11 ADON. The Unit Secretary gave a copy to the charge nurse on duty.

During this same interview with S4 LPN, she verified Patient #4 was outside without staff among other patient's family members attempting to smoke. She stated he had wheeled himself outside. S4 LPN confirmed there was no staff member on the outside with Patient #4. She verified that no staff had gone outside with Patient #4 and no one observed him fall. After a private sitter for another patient had alerted her of Patient #4 falling, she stated she went outside to help patient get back into the wheelchair. S4 confirmed it was when she was "checking the patient over" that she discovered the laceration behind the ear. S4 stated she cleaned the wound and dressed it with clean gauze.

S4LPN stated on 6/3/12, Patient #4 had fallen again in the dining room. She stated S7 MD had reordered 1:1 sitters at 7:30 p.m. S4 LPN stated patient #4 had 1:1 sitters until 6/6/12 until he was discharged. She stated S7 MD had ordered patient needs 24 hour supervision when he returns home because his was a Fall risk.

On 6/13/12 at 3:15 p.m. in a face-to-face interview with S9 CNA/Tech, she stated she assisted S12 CNA with Patient #4 with his Bowel/Bladder training program. When asked if the physician wants a patient to be on 1:1, S9 stated it means total patient care, staying with the patient at all times. If the physician orders "not to leave patient unattended" or "to keep patient in sight at all times", S9 CNA stated someone needs to be with the patient at all times. S9 CNA stated they do not document in the chart when they have to sit with patients on a 1:1. S9CNA confirmed she was with Patient #4 on 5/25/12 from 1:00 p.m. to 2:00 p.m. She denied she brought Patient #4 outside. S9 stated when she brings a patient outside, she stays with the patient.

On 6/14/12 at 10:00 a.m. in a telephone interview with S7 MD, Medical Director, she confirmed she orders 1:1 sitters when patients fall. When she discontinues 1:1 sitters, but orders the patient "Not to be left unattended", S7 MD stated she expects someone to assume responsibility for the patient. S7 stated it could be the nurse assigned to the patient or the CNA assigned to the patient. S7 MD stated she expects the nursing staff to be by the patient at all times. When she orders a patient "Not to be out of eyesight," S7 MD stated she expects nursing staff to keep the patient in view at all times. S7 MD stated she expected the nursing staff to know what she means when she writes orders, such as "1:1 sitter", "do not leave patient unattended," or "patient not to be out of sight." S7 stated she knows the night shift understands what she means when she rights these orders, but she is not sure about the day shift. S7 MD stated family members can be with a patient in preparation for the Transitional Living Arrangements (TLA). She stated she encourages some family members to stay with the patient because it helps them to adjust to the changes they will be facing when the patient leaves the hospital. S7 MD added that when she scheduled a family conference with Patient #4's family, only one family member was present.
Record review of Policy No.: II-A.1.07 titled "Fall Prevention Protocol" issued 10/05, Revised 04/10, under Interventions #14. revealed the following: "Consider placement in room or area of high visibility."

Record review of Policy No.: I-E.5.00 titled "Organizational Performance Improvement Plan" (pg 6 of 17) under Organization revealed: "To provide quality patient care services, the organization educates patient care staff initially after hire, annually, and on a on-going basis." The Goals of Performance Improvement (pg 2 of 17) includes "Safety of the patient (and others) to whom the services are provided."

Based on incident reports, interviews, and policy reviews, the hospital failed to monitor the effectiveness, safety, and quality of care as evidenced by failing to follow their policy of improving organizational performance of reporting accurate data to the Governing Body. Findings:

Record review of Policy No.: I-E.5.00 (pg 5 of 17) notes "Assessment of the performance of the following patient care and organizational functions are included: Safety/Risk Management (Patient/employee falls/injuries...); and Management of Information (Form revision, policy and procedure changes).

Safety/Risk Management:
On 6/14/12 at 3:17 p.m. in a face-to face interview with S2 DON, she confirmed she was the person who tracks and trends data from the different departments. She added S1 CEO reports the information to the Board members.

Record review of January 2012 Fall Report prepared by S2 DON dated 2/8/12 revealed S2 DON listed Total Falls for the Month was 5. Record review of the Fall Incident Report Forms for the month of January revealed there were a total of 10 falls. On 6/14/12 at 3:00 p.m. S2 DON confirmed her report indicated there were only 5 falls in the month of January. She verified there were 10 Fall Incident Report Forms confirming there were 10 falls in the month of January.

Record review of February 2012 Fall Report prepared by S2 DON dated 3/2/12 revealed the Total Falls for the Month was 4. Record review of the Fall Incident Report Forms for the month of February revealed a total of 5 falls. On 6/14/12 at 3:00 p.m. S2 DON confirmed her report indicated there were only 4 falls in the month of February. She verified there were 5 Fall Incident Report Forms confirming there were 5 falls in the month of February.

Record review of March 2012 Fall Report prepared by S2 DON dated 3/2/12 revealed the Total Falls for the Month was 9 and Total Falls with Injuries was 1. Record review of the Fall Incident Report Forms for the month of March revealed a total of 12 falls and 2 of these falls resulted in minor injuries. On 6/14/12 at 3:00 p.m. S2 DON confirmed her report indicated there were only 9 falls and 1 minor injury for the month of March. She verified there were 12 Fall Incident Report Forms and 2 Total falls with minor injuries, confirming there were a total of 12 falls in the month of March.

There were no discrepancies in the April 2012 Fall Report prepared by S2 DON on 5/10/12 as evidenced by 5 Fall Incident Report Forms. On the April 2012 Fall Report there were 2 minor injuries, which occurred as the result of the falls.

On 6/14/12 at 3:00 p.m. in a face-to-face interview with S2 DON, she explained the discrepancies in her Fall Report data and the number of Fall Incident Report Forms was due to the fact she was trying to get the data the surveyors asked for in a quick manner and she counted incorrectly.

Management of Information:
On 6/13/12 at 11:30 a.m. in a face-to-face interview with S2 DON, she confirmed the hospital had no policy in place to guide the nursing staff what was expected for an observational status.

S2 DON confirmed there was no timeframe specified in the Policy No. II-C.3.00 "Patient Care Standards" (pg 4 of 4), as to when the assigned physician be contacted for a Patient fall or incident.

S2 DON confirmed the fall data was inaccurate; therefore, the Performance Improvement plan was not being followed.