HospitalInspections.org

Based on interview and document review, the hospital did not have an effective governing body that carried out the functions required of a governing body to provide a safe and secure environment for patients by the following:

Findings:

1. The Governing Body failed to ensure that contracted nursing services were provided in a safe manner. Contracted staff, assigned to a patient's care, did not have access to approved fall risk assessment tools and planned care interventions for fall prevention, which were imbedded in the patient's electronic medical record (EMR).
See A-0084

2. The Governing Body failed to ensure that nursing staff provided care in a safe manner. An approved fall risk assessment was not performed and appropriate interventions for fall prevention were not implemented at the time of a patient fall. In addition, the frequency of post fall assessments was not specified to meet the needs of the patient.
See A-0144

3. The Governing Body failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program evaluated, developed and implemented quality improvement programs that sustained safety and maintained improvement in fall incident reduction for hospitalized patients. An action plan for 2 consecutive months of increased fall incidences had not been developed and implemented.
See A-0283

4. The Governing Body failed to ensure that the hospital wide QAPI program addressed priorities for improved quality of care and patient safety regarding fall incident reduction for hospitalized patients. Opportunities for improvement were not identified and an action plan for 2 consecutive months of increased fall incidences had not been developed and implemented.
See A-0309

5. The Governing Body failed to ensure that nursing staff evaluated and assessed the current and ongoing care needs. A patient's fall risk was not assessed in accordance with the hospital's policy and procedures. In addition, a patient was not assessed in an ongoing manner that met the needs of the patient.
See A-0395

6. The Governing Body failed to ensure that contracted licensed nurses adhered to the hospital's policies and procedures related to fall prevention assessments, care plan implementation and documentation.
See A-0398


The cumulative effect of these systemic problems resulted in the facility's failure to deliver care in compliance with the Condition of Participation for Governing Body and failure to provide a safe and secure environment for patients.

Based on interview and document review, the hospital failed to protect and promote each patients' rights when patient care was not provided in a safe environment for patients by the following:

Findings:

1. Failure to provide care in a safe setting when an approved fall risk assessment was not performed in accordance with the hospital policy and procedures, and planned care interventions for fall prevention were not implemented at the time of a patient fall. In addition, the frequency of post fall nursing assessments was not identified or specified to meet the individual needs of the patient.
See A-0144



The cumulative effect of these systemic problems resulted in the hospital's failure to deliver care in compliance with the Condition of Participation for Patient's Rights and failure to provide patient care in a safe and secure environment.

Based on interview, document and record review, the hospital failed to ensure that an effective quality assessment and performance improvement (QAPI) program was implemented when the hospital:

Findings:

1. Failed to evaluate, develop and implement quality improvement programs that sustained safety and maintained improvement in fall incident reduction for hospitalized patients. An action plan for 2 consecutive months of increased fall incidences had not been developed and implemented.
See A-0283

2. Failed to ensure that the hospital wide QAPI program addressed priorities for improved quality of care and patient safety regarding fall incident reduction for hospitalized patients. Opportunities for improvement were not identified and an action plan for 2 consecutive months of increased fall incidences had not been developed and implemented.
See A-0309


The cumulative effect of these systemic problems resulted in the hospital's failure to deliver care in compliance with the Condition of Participation for QAPI and failure to provide care to their patients in a safe environment.

Based on interview, record and document review, Nursing Leadership did not provide adequate oversight, to establish and maintain safe and effective care of patients, when Nursing Leadership:

Findings:

1. Failed to ensure that a contracted licensed nurse completed a nursing assessment for fall risk in accordance with hospital policy and procedure and care plan interventions for fall prevention were implemented by the nursing staff. In addition, assessments and reassessments to meet patient care and safety needs were not performed after a fall.
See A-0395

2. Failed to ensure that contracted licensed nurses adhered to the hospital's policies and procedures related to fall prevention assessments, care plan implementation and documentation.
See A-0398


The cumulative effect of these systemic practices and issues resulted in the failure of the hospital to deliver statutorily mandated compliance with the Condition of Participation for Nursing Services.

Based on interview, record and document review, the Governing Body failed to ensure that contracted nursing services were provided in a safe manner for 1 of 30 sampled patients (1). Contracted staff, assigned to Patient 1's care, did not have access to approved fall risk assessment tools and planned care interventions for fall prevention, which were embedded in the patient's electronic medical record. Patient 1 fell, sustained a head injury and subsequently died.

Findings:

The hospital's Performance Improvement Plan, dated 2015, was reviewed on 10/13/15 at 11:00 A.M. The plan indicated that the Governing Board has the ultimate authority and responsibility for performance improvement. The Governing Board delegates to the hospital leadership the authority to "... assess and prioritize the performance improvement activities, require mechanisms for, and reports of the monitoring and evaluation of patient care services, provide resources and support systems for performance improvement functions related to services and safety, assure that one level of care is provided for all patients."

The hospital's Performance Improvement Plan, dated 2015, was reviewed on 10/13/15 at 11:00 A.M. The plan indicated that "...planning will provide for collaboration across disciplines and departments to identify and prioritize important opportunities for improvement. These identified areas will reflect high risk, high volume and /or problems." The plan further specified that "the collected data will be assessed systematically using...patterns and trends over time...processes or systems that significantly vary from internal expectations."

A review of the hospital's 2015 patient fall data per month was conducted on 10/13/15 at 9:00 A.M. The data indicated that in January there were 4 falls, February 3 falls, March 8 falls, April 4 falls, May 6 falls, June 2 falls, July 3 falls, August 8 falls and September 13 falls.

A review of the hospital's quality committee meeting minutes, dated April 2015, was conducted on 10/13/15 at 9:45 A.M. The 8 falls in March 2015 was presented in the April 2015 meeting minutes with a recommendation to continue monitoring. There was no documented evidence in the meeting minutes that any action plan was taken for the increase falls in March compared to the prior two months.

A review of the hospital's 2015 quality committee minutes, dated September 2015, was conducted on 10/13/15 at 10:00 A.M. The 8 falls in August 2015 was presented in the September 2015 meeting minutes with a recommendation to establish a "Fall task force committee" and provide training to the nurses regarding the fall prevention program. There was no documented evidence in the meeting minutes that the fall prevention policy had been reviewed or that there was any evaluation or plan to check for nursing staff compliance with the hospital's fall policy and procedure.

The hospital's Fall Prevention and Management Program policy, dated 12/2014, was reviewed on 10/13/15 at 10:30 A.M. The policy specified that "All patients admitted to the inpatient setting will be assessed for fall "risk" using the Modified Morse Fall Risk (an assessment tool which assigns a numerical value to various patient characteristics and identifies a risk for falls based on a total score) on admission, each shift, and change in status of the patient, and prior to discharge." The policy further specified that for post fall assessment the nursing staff should assess patient for level of injury, obtain vital signs and neuro (neurological) checks when appropriate, assess for range of motion, alert physician, assess and treat any injury, assess and treat for level of pain, consider safety devices to prevent further falls and documentation of communication. The policy did not give specific parameters to nursing staff regarding frequency of vital signs or neuro (neurological) assessments and did not differentiate between mechanism and severity of injury and need for more frequent assessments.

An interview with the Director of Quality Management (DQM) was conducted on 10/13/15 at 1:00 P.M. the DQM stated that following the "spike" in falls for March of 2015, an analysis of the data was performed and no trends were identified. The DQM stated that following the increased falls in March of 2015 the hospital did provide education to the nurses regarding the fall prevention program at morning stand up and huddles. The hospital did not provide documentation of sign in sheets for the fall risk nursing education huddles. The DQM acknowledged that the fall prevention policy was not reviewed. The DQM acknowledged there was no evaluation of the nursing staff completion of the Modified Morse Fall Risk Assessment. The DQM further stated that the "spike" in falls for August of 2015 was taken to the Medical Executive committee and that a fall task force committee was established to further investigate the increase in falls.

The DQM acknowledged that following the March and August increases in falls, the quality program did not identify that contracted registry nurses did not have full access to the electronic medical record (EMR) with the embedded Modified Morse Fall Risk assessment tool referenced in the fall prevention policy. The DQM acknowledged that the quality department did not identify that contracted registry nurses were using a paper fall assessment tool that was not the same as the Modified Morse Fall Risk assessment tool to assess patients for fall risk referenced in the hospital's fall prevention policy.

An interview with representatives of the Governing Board was conducted on 10/13/15 at 1:30 P.M. The DQM stated that the data for the two months of increased falls for March and August of 2015 was presented in the Quality and Medical Executive meetings and then flowed up to the Governing Board. The DQM stated that after the increase in falls for August 2015 a recommendation for a fall task force was submitted and approved by the Governing Board. The DQM stated that after Patient 1 fell and sustained a serious head injury, a Root Cause Analysis (RCA. an internal investigation) was performed and the issue with the contracted registry nurses not having access to the EMR was identified. In addition, the Fall Prevention policy was also reviewed and opportunities for improvement were identified.

Based on interview and record review the hospital failed to provide care in a safe manner for 1 of 30 sampled patients (1). An approved fall risk assessment was not performed in accordance with the hospital policy and procedures, and planned care interventions for fall prevention were not implemented at the time of Patient 1's fall. In addition, the frequency of post fall nursing assessments was not identified or specified to meet the individual needs of the patient. Patient 1 fell, sustained a head injury, which was then diagnosed as a subdural hematoma (bleeding within the brain) and died.

Findings:

Patient 1 was admitted to the hospital (long term acute care hospital) on 9/16/15 with diagnoses which included multiple skin abscesses (infected skin wounds) and hepatic encephalopathy (a metabolic brain disorder which can occur in advanced liver disease and cause impaired memory and intellectual function) per the physician's Admission History and Physical Examination document, dated 9/16/15. The same document included that Patient 1 was on deep venous thrombosis prophylaxes (an anticoagulant medication regime used to slow blood clotting time and decrease blood clot formation).

During an interview on 10/6/15 at 1:00 P.M., the Director of Quality Management (DQM) stated that Patient 1 sustained a witnessed fall on the morning of 9/29/15, while the patient was in the hospital. The DQM stated that Patient 1 developed a change of condition after the fall and had been transferred to another Hospital (B - a general acute care hospital) for emergency services on the day of the fall. The DQM stated Hospital B had informed them of the patient's death on 10/2/15.

During an interview and joint record/document review on 10/6/15 at 2:00 P.M., Medical Doctor (MD) 1 stated that he was on day shift duty 9/29/15 and responded to Patient 1's room when called by nursing staff. MD 1 stated he was informed by the nursing staff that Patient 1 had sustained a fall "about an hour ago". MD 1 stated he examined the patient and observed a "boggy hematoma" (an abnormal soft formation of blood outside of a blood vessel) on the back of the patient's head. A review of MD 1's Chart Note, dated 9/29/15 at 8:19 A.M., described the hematoma as "R (right) occipital (lower back of the head) scalp... large...6 x 8 cm (centimeters) in size..." MD 1 stated the patient was non verbal, unresponsive to pain, had a decreased level of conscious and that the patient's eye pupils were "poorly responsive" (a symptom of impaired brain function). The same Chart Note included that Patient 1 had been administered a 10 mg (milligram) dose of Ambien (a sedative medication with potential side effects which can induce forgetfulness and impaired judgement/physical function) on the night shift of the fall occurrence. MD 1 stated that he instructed the hospital staff to call 911 for emergency transport.

During an interview on 10/6/15 at 3:00 P.M., the DQM stated that "all" of the hospital patient beds have the built in capability to be alarmed to detect exit from the bed. The DQM stated that the alarm function can be turned turned on or off manually. The DQM stated that hospitalized patients that were assessed at high risk for falls should have "full" fall prevention interventions in place, which would include an engaged bed exit alarm. The DQM stated that Patient 1 had been previously assessed as a high fall risk and at the time of the fall, the patient's bed exit alarm was not turned on. The DQM stated that the hospital licensed nursing staff were responsible for the assessment of assigned patients on each shift (7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M.) The DQM stated the hospital used the Modified Morse Fall Scale (an assessment tool which assigns a numerical value to various patient characteristics and identifies a risk for falls based on a total score). The DQM stated that the Modified Morse Fall Scale was embedded in the hospital electronic medical record document and was available for use by the "regular" nursing staff and "some" contract temporary nurses. The DQM stated that a paper version, of the same Modified Morse Fall Scale, had not been made available to licensed nurses unable to access the assessment tool in the electronic medical record (EMR).

A review of the hospital's electronic Patient Assessment Report document, dated 9/28/15 at 7:30 A.M., indicated an assessment of Patient 1's physical status. The same report included the "Morse Fall Risk" assessment and identified "Morse Fall Scale Total 50.00". The Morse Fall Risk assessment tool identifies total numerical scores of 45 or greater as a high risk for falls. There was no evidence of Patient 1's Modified Morse Fall Scale assessment for the 9/28/15 7:00 P.M. to 7:00 A.M. shift.

During an interview on 10/6/15 at 3:10 P.M., Registered Nurse (RN) 1 stated that the hospital used the Modified Morse Fall Scale assessment tool, on every 12 hour shift, to identify patients at high risk for falls. RN 1 stated that bed exit alarms were to be implemented for patients identified at "high" risk for falls. RN 1 stated it was the joint responsibility of the patient's primary nurse and the assigned Certified Nursing Assistant (CNA) staff to check the bed alarms of "high risk" patients, each shift, and "make sure they are turned on".

During an interview on 10/7/15 at 9:45 A.M., CNA 1 stated she was assigned to Patient 1 on the night of the patient's fall occurrence. CNA 1 stated that she was not aware if Patient 1 was at risk for falls and that the patient's fall risk status and interventions had not been discussed with the patient's primary nurse. In addition, CNA 1 stated it was her responsibility to check patient bed alarms each shift, however she could not recall if she had checked Patient 1's bed alarm. CNA 1 recalled that she was in the patient's room, at the time of the fall occurrence. CNA 1 stated that she heard the sound of a "hard thump" and a call for help from RN 2. CNA 1 stated that the patient's bed alarm had not sounded. CNA 1 stated that she then summoned assistance, brought an electronic blood pressure machine to the room and then left as others arrived. CNA 1 stated that she did not assess a blood pressure and was not instructed to monitor the patient's blood pressure after the fall occurrence.

During an interview and joint record/document review on 10/7/15 at 10:15 A.M., RN 2 stated that he was a contracted temporary licensed nurse and had been assigned as Patient 1's primary nurse on the shift of the patient's fall occurrence. RN 2 stated that he received a verbal report of the patient's status, however the patient's fall risk status was not discussed. RN 2 stated Patient 1 was "up with assist...seemed oriented...but weak at time of return to bed", at 10:00 P.M. RN 2 stated that the patient was also given a dose of the medication Ambien at that time. RN 2 stated "I thought the patient was at moderate risk for falls" however, RN 2 acknowledged that he had not used the Modified Morse Fall Scale to make that assessment. RN 2 stated that he did not have access to the patient's electronic record for use of the assessment tools or viewing of patient care plan interventions. RN 2 stated that he used a paper version of an assessment tool, which did not include the Modified Morse Fall Scale. RN 2 stated that he was in Patient 1's room at the time of the fall occurrence. RN 2 stated that a bed alarm did not sound, but he noticed Patient 1 had exited his bed and entered an adjacent toilet area. RN 2 stated that he then witnessed Patient 1 fall "over backwards" from the toilet area directly to the floor with a "loud thump" and struck his head. RN 2 stated that nursing and medical staff responded to a call for assistance and he reported that the patient had "hit hard". RN 2 stated that a responding medical doctor had gave directions, which included "monitor the patient", however the specific monitoring and frequency parameters were not identified, clarified or ordered. RN 2 stated that he performed 2 blood pressure measurements and "neuro checks (eye pupil response)" between 6:55 A.M. and 7:00 A.M. and "more later". RN 2 stated at 7:40 A.M., he returned to assess Patient 1 and found the patient unable to respond verbally and with a decreased level of consciousness. A joint review of the paper version of Patient 1's Medical/Surgical Flowsheet assessment, dated "9/28/15 PM", revealed no documentation of ongoing patient blood pressure measurements or neuro checks from 7:00 A.M. until 7:40 A.M. In addition, a review of the patient's Neurological Assessment Flow Sheet form, dated 9/29/15, revealed no documentation of Patient 1's assessments between 7:00 A.M. and 7:40 A.M.

During an interview on 10/7/15 at 11:30 A.M., RN 3 stated that she was a shift nursing supervisor and responded to the call for assistance (Rapid Response Code) in Patient 1's room on the day of the fall occurrence. RN 3 stated that she heard Medical Doctor (MD) 3 give an order for a head CAT scan (computerized axial tomography special radiology test to image disease or injury) and began to make arrangements for the procedure. RN 3 stated the hospital's policy and procedure related to falls included every 30 minute assessment of post fall neuro checks and vital signs (assessment of blood pressure, pulse, respirations, pain). RN 3 stated that RN 2 was a contracted temporary nurse and did not have access to the patient's electronic record. RN 3 stated that RN 2 had "questions" about hospital forms and monitoring, after the patient's fall. RN 3 stated that RN 2 then reported that he had discovered that the patient had a change of condition. RN 3 stated that MD 1 was summoned to assess the patient and ordered 911 transport to an emergency department.

A review of Patient 1's hospital special physician order form, entitled Venous Thromboembolism Prophylaxis Order Form, dated 9/17/15 included "Heparin (an anticoagulation medication used to slow blood clotting time) 5,000 units subcutaneously (injection administered within the skin layers) BID (twice daily)."
A review of Patient 1's Medication Administration Record (MAR) indicated the Heparin had been administered as ordered since 9/17/15.

During an interview and joint record review on 10/7/15 at 1:00 P.M., the Physical Therapist (PT) reviewed PT Daily Notes, dated 9/28/15 and stated Patient 1 required standby assistance with walking, used a forward wheeled walker (rolling device to aid in balance) and that a bed exit alarm was in use. The PT stated that the patient required prompting to recall instructions and demonstrated cognitive impairment when asked "open ended" questions.

During an interview and joint record review on 10/7/15 at 1:30 P.M., the Occupational Therapist (OT) reviewed the OT Daily Notes, dated 09/28/15 and stated that Patient 1 was not safe to independently toilet and needed supervision assistance. In addition, the OT stated that Patient 1 demonstrated "impulsiveness" and was "a candidate for a bed exit alarm."

A review of Patient 1's care plan, dated 9/17/15, identified the ongoing problem "FALL AND INJURY RISK" and the objective "FREE FROM FALL AND INJURY". The interventions included "BED EXIT ALARM...LOW BED...YELLOW ARMBAND". In addition, the care plan identified the problem "ALTERED MOBILITY" with interventions that included "ASSIST WITH ADLS (activities of daily living)".

A review of the hospital policy and procedure, dated "12/14", included "All patients admitted to the inpatient setting will be assessed for fall "risk" using the Modified Morse Fall Risk on admission, each shift...Safety devices will be initiated when indicated according to policy as soon as possible once the patient is assessed as being "at risk" for falling...Fall Risk Assessment: If any of these medical factors are present the patient may be at "risk" for falls...infection, toxic/metabolic...sleep disturbances...Meds...anticoagulant...Impaired mobility...Standard Fall Prevention Interventions: Assess patient's fall risk...each shift...High Risk Fall Prevention Interventions: These interventions are designed to be implemented for patients with multiple fall risk factors... Use for those who score High Risk on the Fall Risk Assessment (>45 on Modified Morse Fall Risk Assessment)...Consider use of safety technology for fall prevention...Yellow wristband...Bed and chair alarm...Assessment of the patient post fall: Obtain vital signs and neuro checks when appropriate..."

A review of the hospital policy and procedure entitled Assessment and Reassessment, dated 10/22/13 included "Patients at [name of hospital] receive care based upon a documented assessment of patient care needs and problem identification...Patient needs, response to treatment/intervention, and change in condition or diagnoses are reassessed as necessary and a minimum of every shift...The routine re-assessment of patient's status includes a system review every shift (12 hours)...Documentation of the (re)assessments will be entered into the Electronic Medical Record (EMR)."

A review of the hospital policy and procedure entitled Nursing Planning, dated "5/14" included "It communicates pertinent patient problems/needs, delineates appropriate medical and nursing interventions to meet these needs, and documents the effectiveness of the interventions in the medical record."

A review of the hospital policy and procedure entitled Patients Rights and Responsibilities, dated "11/13" included "Expect emergency procedures to be implemented without unnecessary delay...Personal Safety. The patient has the right to expect safety insofar as the hospital practices and environment are concerned."

A review of Hospital B's Emergency Record, dated 9/29/15, indicated that Patient 1 arrived via paramedic transport at 8:04 A.M. The Emergency Record included "This patient [Patient 1] presents with profound depressed mental status, status post report fall with head trauma. He is in critical condition and is severely encephalopathic (decreased brain function) and is not protecting his airway. He required emergent endotracheal intubation (insertion of a tube to assist breathing)...Impression:Acute encephalopathy status post fall...Acute neurologic failure status post mechanical fall...Acute respiratory failure status post mechanical fall." A Neurosurgical Consultation (brain specialist) report, dated 9/29/15, indicated that Patient 1 was diagnosed with an acute subdural hematoma (bleeding within the brain).

During an interview and record/document review on 10/13/15 at 11:00 A.M., the DQM acknowledged that Patient 1's safety had not been maintained when the patient's risk for falls had not been assessed per the hospital's policy and procedure on the shift of a fall occurrence. The DQM acknowledged that the patient's bed exit alarm, which had been identified as a care plan fall prevention intervention, had not been implemented at the time of the patient's fall. In addition, the DQM acknowledged policies and procedures for nursing assessment and care planning and post fall nursing care had not been implemented as planned. In addition, the DQM acknowledged that the hospital post fall policy and procedure were not specific and post fall assessments were not conducted in a manner that met the needs of a patient who had sustained a witnessed fall and head injury.

Based on interview and document review, the hospital's Quality Assessment and Performance Improvement (QAPI) program failed to evaluate, develop and implement quality improvement programs that sustained safety and maintained improvement in fall incident reduction for hospitalized patients. An action plan for 2 consecutive months of increased fall incidences had not been developed and implemented.

Findings:

The hospital's Performance Improvement Plan, dated 2015, was reviewed on 10/13/15 at 11:00 A.M. The plan indicated that "...planning will provide for collaboration across disciplines and departments to identify and prioritize important opportunities for improvement. These identified areas will reflect high risk, high volume and /or problems." The plan further specified that "the collected data will be assessed systematically using...patterns and trends over time...processes or systems that significantly vary from internal expectations."

A review of the hospital's 2015 patient fall data per month was conducted on 10/13/15 at 9:00 A.M. The data indicated that in January there were 4 falls, February 3 falls, March 8 falls, April 4 falls, May 6 falls, June 2 falls, July 3 falls, August 8 falls and September 13 falls.

A review of the hospital's quality committee meeting minutes dated April 2015 was conducted on 10/13/15 at 9:45 A.M. The 8 falls in March 2015 was presented in the April 2015 meeting minutes with a recommendation to continue monitoring. There was no documented evidence in the meeting minutes that any action plan was taken for the increase falls in March compared to the prior two months.

A review of the hospital's 2015 quality committee minutes, dated September 2015, was conducted on 10/13/15 at 10:00 A.M. The 8 falls in August 2015 was presented in the September 2015 meeting minutes with a recommendation to establish a "Fall task force committee" and provide training to the nurses regarding the fall prevention program. There was no documented evidence in the meeting minutes that the fall prevention policy had been reviewed or that there was any evaluation or plan to check for nursing staff compliance with the hospital's fall policy and procedure.

The hospital's Fall Prevention and Management Program policy, dated 12/2014, was reviewed on 10/13/15 at 10:30 A.M. The policy specified that "All patients admitted to the inpatient setting will be assessed for fall "risk" using the Modified Morse Fall Risk (an assessment tool which assigns a numerical value to various patient characteristics and identifies a risk for falls based on a total score) on admission, each shift, and change in status of the patient, and prior to discharge." The policy further specified that for post fall assessment the nursing staff should assess patient for level of injury, obtain vital signs and neuro (neurological) checks when appropriate, assess for range of motion, alert physician, assess and treat any injury, assess and treat for level of pain, consider safety devices to prevent further falls and documentation of communication. The policy did not give specific parameters to nursing staff regarding frequency of vital signs or neuro assessments and did not differentiate between mechanism or severity of injury and need for more frequent assessments.

An interview with the Director of Quality Management (DQM) was conducted on 10/13/15 at 1:00 P.M. The DQM stated that following the "spike" in falls for March of 2015, an analysis of the data was performed and no trends were identified. The DQM stated that following the increased falls in March of 2015 the hospital did provide education to the nurses regarding the fall prevention program at morning stand up and huddles. The hospital did not provide documentation of sign in sheets for the fall risk nursing education huddles. The DQM acknowledged that the fall prevention policy was not reviewed. The DQM acknowledged that the nursing staff completion of the Modified Morse Fall Risk Assessment was not evaluated. The DQM further stated that the "spike" in falls for August of 2015 was taken to the Medical Executive committee and that a fall task force committee was established to further investigate the increase in falls. The DQM acknowledged that following the March and August increases in falls, the quality program did not identify that contracted registry nurses did not have full access to the electronic medical record (EMR) with the embedded Modified Morse Fall Risk assessment tool referenced in the fall prevention policy. The DQM acknowledged that the Quality Department did not identify that the registry nurses were using a paper fall assessment that was not the same as the Modified Morse Fall Risk assessment tool to assess patients for fall risk.

Based on interview, policy and document review, the Governing Body failed to ensure that the hospital wide Quality Assessment and Performance Improvement (QAPI) program addressed priorities for improved quality of care and patient safety regarding fall incident reduction for hospitalized patients. Opportunities for improvement were not identified and an action plan for 2 consecutive months of increased fall incidences had not been developed and implemented.

Findings:

The hospital's Performance Improvement Plan, dated 2015, was reviewed on 10/13/15 at 11:00 A.M. The plan indicated that the Governing Board has the ultimate authority and responsibility for performance improvement. The Governing Board delegates to the hospital leadership the authority to...assess and prioritize the performance improvement activities, require mechanisms for, and reports of the monitoring and evaluation of patient care services, provide resources and support systems for performance improvement functions related to services and safety, assure that one level of care is provided for all patients.

The hospital's Performance Improvement Plan, dated 2015, was reviewed on 10/13/15 at 11:00 A.M. The plan indicated that "...planning will provide for collaboration across disciplines and departments to identify and prioritize important opportunities for improvement. These identified areas will reflect high risk, high volume and /or problems." The plan further specified that "the collected data will be assessed systematically using...patterns and trends over time...processes or systems that significantly vary from internal expectations."

A review of the hospital's 2015 patient fall data per month was conducted on 10/13/15 at 9:00 A.M. The data indicated that in January there were 4 falls, February 3 falls, March 8 falls, April 4 falls, May 6 falls, June 2 falls, July 3 falls, August 8 falls and September 13 falls.

A review of the hospital quality committee meeting minutes, dated April 2015, was conducted on 10/13/15 at 9:45 A.M. The 8 falls in March 2015 was presented in the April 2015 meeting minutes with a recommendation to continue monitoring. There was no documented evidence in the meeting minutes that any action plan was taken for the increase falls in March compared to the prior two months.

A review of the hospital's 2015 quality committee minutes, dated September 2015, was conducted on 10/13/15 at 10:00 A.M. The 8 falls in August 2015 was presented in the September 2015 meeting minutes with a recommendation to establish a "Fall task force committee" and provide training to the nurses regarding the fall prevention program. There was no documented evidence in the meeting minutes that the fall prevention policy had been reviewed or that there was any evaluation or plan to check for nursing staff compliance with the hospital's fall policy and procedure.

The hospital's Fall Prevention and Management Program policy, dated 12/2014, was reviewed on 10/13/15 at 10:30 A.M. The policy specified that "All patients admitted to the inpatient setting will be assessed for fall "risk" using the Modified Morse Fall Risk (an assessment tool which assigns a numerical value to various patient characteristics and identifies a risk for falls based on a total score) on admission, each shift, and change in status of the patient, and prior to discharge." The policy further specified that for post fall assessment the nursing staff should assess patient for level of injury, obtain vital signs and neuro (neurological) checks when appropriate, assess for range of motion, alert physician, assess and treat any injury, assess and treat for level of pain, consider safety devices to prevent further falls and documentation of communication. The policy did not give specific parameters to nursing staff regarding frequency of vital signs or neuro (neurological) assessments and did not differentiate between mechanism and severity of injury and need for more frequent assessments.

An interview with the Director of Quality Management (DQM) was conducted on 10/13/15 at 1:00 P.M. The DQM stated that following the "spike" in falls for March of 2015, an analysis of the data was performed and no trends were identified. The DQM stated that following the increased falls in March of 2015 the hospital did provide education to the nurses regarding the fall prevention program at morning stand up meetings and "huddles". The hospital did not provide documentation of sign in sheets for the fall risk nursing education huddles. The DQM acknowledged that the fall prevention policy was not reviewed. The DQM acknowledged that the nursing staff completion of the Modified Morse Fall Risk Assessment was not evaluated. The DQM further stated that the "spike" in falls for August of 2015 was taken to the Medical Executive committee and that a fall task force committee was established to further investigate the increase in falls.

The DQM acknowledged that following the March and August increases in falls, the quality program did not identify that contracted registry nurses did not have full access to the electronic medical record (EMR) with the embedded Modified Morse Fall Risk assessment tool referenced in the fall prevention policy. The DQM acknowledged that the Quality Department did not identify that contracted registry nurses were using a paper fall assessment tool that was not the same as the Modified Morse Fall Risk assessment tool to assess patients for fall risk referenced in the hospital's fall prevention policy.

An interview with representatives of the Governing Board was conducted on 10/13/15 at 1:30 P.M. The DQM stated that the data for the two months of increased falls for March and August of 2015 was presented in the Quality and Medical Executive meetings and then flowed up to the Governing Board. The DQM stated that after the increase in falls for August 2015 a recommendation for a fall task force was submitted and approved by the Governing Board. The DQM stated that after Patient 1 fell and sustained a serious head injury, a Root Cause Analysis (RCA - an internal investigation) was performed. The investigation identified the issue with the contracted registry nurses not having access to the EMR. In addition, the Fall Prevention policy was also reviewed and opportunities for improvement were identified.

Based on interview and record review the hospital failed to ensure that nursing services were implemented to meet patient needs for 1 of 30 sampled patients (1). A contracted licensed nurse did not complete a nursing assessment for fall risk in accordance with hospital policy and procedure. Care plan interventions for fall prevention were not implemented by the nursing staff. In addition, assessments and reassessments to meet patient care and safety needs were not performed after a fall. Patient 1 fell, sustained a head injury, and had a change of condition which was then diagnosed as a subdural hematoma (bleeding within the brain) and died.

Findings:

Patient 1 was admitted to the hospital (long term acute care hospital) on 9/16/15 with diagnoses which included multiple skin abscesses (infected skin wounds) and hepatic encephalopathy (a metabolic brain disorder which can occur in advanced liver disease and cause impaired memory and intellectual function) per the physician's Admission History and Physical Examination document, dated 9/16/15. The same document included that Patient 1 was on deep venous thrombosis prophylaxes (an anticoagulant medication regime used to slow blood clotting time and decrease blood clot formation).

During an interview on 10/6/15 at 1:00 P.M., the Director of Quality Management (DQM) stated that Patient 1 sustained a witnessed fall on the morning of 9/29/15, while the patient was in the hospital. The DQM stated that Patient 1 developed a change of condition after the fall and had been transferred to another Hospital (B - a general acute care hospital) for emergency services on the day of the fall. The DQM stated Hospital B had informed them of the patient's death on 10/2/15.

During an interview and joint record/document review on 10/6/15 at 2:00 P.M., Medical Doctor (MD) 1 stated that he was on day shift duty 9/29/15 and responded to Patient 1's room when called by nursing staff. MD 1 stated he was informed by the nursing staff that Patient 1 had sustained a fall "about an hour ago". MD 1 stated he examined the patient and observed a "boggy hematoma" (an abnormal soft formation of blood outside of a blood vessel) on the back of the patient's head. A review of MD 1's Chart Note, dated 9/29/15 at 8:19 A.M., described the hematoma as "R (right) occipital (lower back of the head) scalp... large...6 x 8 cm (centimeters) in size..." MD 1 stated the patient was non verbal, unresponsive to pain, had a decreased level of conscious and that the patient's eye pupils were "poorly responsive" (a symptom of impaired brain function). The same Chart Note included that Patient 1 had been administered a 10 mg (milligram) dose of Ambien (a sedative medication with potential side effects which can induce forgetfulness and impaired judgement/physical function) on the night shift of the fall occurrence. MD 1 stated that he instructed the hospital staff to call 911 for emergency transport.

During an interview on 10/6/15 at 3:00 P.M., the DQM stated that "all" of the hospital patient beds have the built in capability to be alarmed to detect exit from the bed. The DQM stated that the alarm function can be turned turned on or off manually. The DQM stated that hospitalized patients that were assessed at high risk for falls should have "full" fall prevention interventions in place, which would include an engaged bed exit alarm. The DQM stated that Patient 1 had been previously assessed as a high fall risk and at the time of the fall, the patient's bed exit alarm was not turned on. The DQM stated that the hospital licensed nursing staff were responsible for the assessment of assigned patients on each shift (7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M.) The DQM stated the hospital used the Modified Morse Fall Scale (an assessment tool which assigns a numerical value to various patient characteristics and identifies a risk for falls based on a total score). The DQM stated that the Modified Morse Fall Scale was embedded in the hospital electronic medical record document and was available for use by the "regular" nursing staff and "some" contract temporary nurses. The DQM stated that a paper version, of the same Modified Morse Fall Scale, had not been made available to licensed nurses unable to access the assessment tool in the electronic medical record (EMR).

A review of the hospital's electronic Patient Assessment Report document, dated 9/28/15 at 7:30 A.M., indicated an assessment of Patient 1's physical status. The same report included the "Morse Fall Risk" assessment and identified "Morse Fall Scale Total 50.00". The Morse Fall Risk assessment tool identifies total numerical scores of 45 or greater as a high risk for falls. There was no evidence of Patient 1's Modified Morse Fall Scale assessment for the 9/28/15 7:00 P.M. to 7:00 A.M. shift.

During an interview on 10/6/15 at 3:10 P.M., Registered Nurse (RN) 1 stated that the hospital used the Modified Morse Fall Scale assessment tool, on every 12 hour shift, to identify patients at high risk for falls. RN 1 stated that bed exit alarms were to be implemented for patients identified at "high" risk for falls. RN 1 stated it was the joint responsibility of the patient's primary nurse and the assigned Certified Nursing Assistant (CNA) staff to check the bed alarms of "high risk" patients, each shift, and "make sure they are turned on".

During an interview on 10/7/15 at 9:45 A.M., CNA 1 stated she was assigned to Patient 1 on the night of the patient's fall occurrence. CNA 1 stated that she was not aware if Patient 1 was at risk for falls and that the patient's fall risk status and interventions had not been discussed with the patient's primary nurse. In addition, CNA 1 stated it was her responsibility to check patient bed alarms each shift, however she could not recall if she had checked Patient 1's bed alarm. CNA 1 recalled that she was in the patient's room, at the time of the fall occurrence. CNA 1 stated that she heard the sound of a "hard thump" and a call for help from RN 2. CNA 1 stated that the patient's bed alarm had not sounded. CNA 1 stated that she then summoned assistance, brought an electronic blood pressure machine to the room and then left as others arrived. CNA 1 stated that she did not assess a blood pressure and was not instructed to monitor the patient's blood pressure after the fall occurrence.

During an interview and joint record/document review on 10/7/15 at 10:15 A.M., RN 2 stated that he was a contracted temporary licensed nurse and had been assigned as Patient 1's primary nurse on the shift of the patient's fall occurrence. RN 2 stated that he received a verbal report of the patient's status, however the patient's fall risk status was not discussed. RN 2 stated Patient 1 was "up with assist...seemed oriented...but weak at time of return to bed", at 10:00 P.M. RN 2 stated that the patient was also given a dose of the medication Ambien at that time. RN 2 stated "I thought the patient was at moderate risk for falls" however, RN 2 acknowledged that he had not used the Modified Morse Fall Scale to make that assessment. RN 2 stated that he did not have access to the patient's electronic record for use of the assessment tools or viewing of patient care plan interventions. RN 2 stated that he used a paper version of an assessment tool, which did not include the Modified Morse Fall Scale. RN 2 stated that he was in Patient 1's room at the time of the fall occurrence. RN 2 stated that a bed alarm did not sound, but he noticed Patient 1 had exited his bed and entered an adjacent toilet area. RN 2 stated that he then witnessed Patient 1 fall "over backwards" from the toilet area directly to the floor with a "loud thump" and struck his head. RN 2 stated that nursing and medical staff responded to a call for assistance and he reported that the patient had "hit hard". RN 2 stated that a responding medical doctor had gave directions, which included "monitor the patient", however the specific monitoring and frequency parameters were not identified, clarified or ordered. RN 2 stated that he performed 2 blood pressure measurements and "neuro checks (eye pupil response)" between 6:55 A.M. and 7:00 A.M. and "more later". RN 2 stated at 7:40 A.M., he returned to assess Patient 1 and found the patient unable to respond verbally and with a decreased level of consciousness. A joint review of the paper version of Patient 1's Medical/Surgical Flowsheet assessment, dated "9/28/15 PM", revealed no documentation of ongoing patient blood pressure measurements or neuro checks from 7:00 A.M. until 7:40 A.M. In addition, a review of the patient's Neurological Assessment Flow Sheet form, dated 9/29/15, revealed no documentation of Patient 1's assessments between 7:00 A.M. and 7:40 A.M.

During an interview on 10/7/15 at 11:30 A.M., RN 3 stated that she was a shift nursing supervisor and responded to the call for assistance (Rapid Response Code) in Patient 1's room on the day of the fall occurrence. RN 3 stated that she heard Medical Doctor (MD) 3 give an order for a head CAT scan (computerized axial tomography special radiology test to image disease or injury) and began to make arrangements for the procedure. RN 3 stated the hospital's policy and procedure related to falls included every 30 minute assessment of post fall neuro checks and vital signs (assessment of blood pressure, pulse, respirations, pain). RN 3 stated that RN 2 was a contracted temporary nurse and did not have access to the patient's electronic record. RN 3 stated that RN 2 had "questions" about hospital forms and monitoring, after the patient's fall. RN 3 stated that RN 2 then reported that he had discovered that the patient had a change of condition. RN 3 stated that MD 1 was summoned to assess the patient and ordered 911 transport to an emergency department.

A review of Patient 1's hospital special physician order form, entitled Venous Thromboembolism Prophylaxis Order Form, dated 9/17/15 included "Heparin (an anticoagulation medication used to slow blood clotting time) 5,000 units subcutaneously (injection administered within the skin layers) BID (twice daily)."
A review of Patient 1's Medication Administration Record (MAR) indicated the Heparin had been administered as ordered since 9/17/15.

During an interview and joint record review on 10/7/15 at 1:00 P.M., the Physical Therapist (PT) reviewed PT Daily Notes, dated 9/28/15 and stated Patient 1 required standby assistance with walking, used a forward wheeled walker (rolling device to aid in balance) and that a bed exit alarm was in use. The PT stated that the patient required prompting to recall instructions and demonstrated cognitive impairment when asked "open ended" questions.

During an interview and joint record review on 10/7/15 at 1:30 P.M., the Occupational Therapist (OT) reviewed the OT Daily Notes, dated 09/28/15 and stated that Patient 1 was not safe to independently toilet and needed supervision assistance. In addition, the OT stated that Patient 1 demonstrated "impulsiveness" and was "a candidate for a bed exit alarm."

A review of Patient 1's care plan, dated 9/17/15, identified the ongoing problem "FALL AND INJURY RISK" and the objective "FREE FROM FALL AND INJURY". The interventions included "BED EXIT ALARM...LOW BED...YELLOW ARMBAND". In addition, the care plan identified the problem "ALTERED MOBILITY" with interventions that included "ASSIST WITH ADLS (activities of daily living)".

A review of the hospital policy and procedure, dated "12/14", included "All patients admitted to the inpatient setting will be assessed for fall "risk" using the Modified Morse Fall Risk on admission, each shift...Safety devices will be initiated when indicated according to policy as soon as possible once the patient is assessed as being "at risk" for falling...Fall Risk Assessment: If any of these medical factors are present the patient may be at "risk" for falls...infection, toxic/metabolic...sleep disturbances...Meds...anticoagulant...Impaired mobility...Standard Fall Prevention Interventions: Assess patient's fall risk...each shift...High Risk Fall Prevention Interventions: These interventions are designed to be implemented for patients with multiple fall risk factors... Use for those who score High Risk on the Fall Risk Assessment (>45 on Modified Morse Fall Risk Assessment)...Consider use of safety technology for fall prevention...Yellow wristband...Bed and chair alarm...Assessment of the patient post fall: Obtain vital signs and neuro checks when appropriate..."

A review of the hospital policy and procedure entitled Assessment and Reassessment, dated 10/22/13 included "Patients at [name of hospital] receive care based upon a documented assessment of patient care needs and problem identification...Patient needs, response to treatment/intervention, and change in condition or diagnoses are reassessed as necessary and a minimum of every shift...The routine re-assessment of patient's status includes a system review every shift (12 hours)...Documentation of the (re)assessments will be entered into the Electronic Medical Record (EMR)."

A review of the hospital policy and procedure entitled Nursing Planning, dated "5/14" included "It communicates pertinent patient problems/needs, delineates appropriate medical and nursing interventions to meet these needs, and documents the effectiveness of the interventions in the medical record."

A review of the hospital policy and procedure entitled Patients Rights and Responsibilities, dated "11/13" included "Expect emergency procedures to be implemented without unnecessary delay...Personal Safety. The patient has the right to expect safety insofar as the hospital practices and environment are concerned."

A review of Hospital B's Emergency Record, dated 9/29/15, indicated that Patient 1 arrived via paramedic transport at 8:04 A.M. The Emergency Record included "This patient [Patient 1] presents with profound depressed mental status, status post report fall with head trauma. He is in critical condition and is severely encephalopathic (decreased brain function) and is not protecting his airway. He required emergent endotracheal intubation (insertion of a tube to assist breathing)...Impression:Acute encephalopathy status post fall...Acute neurologic failure status post mechanical fall...Acute respiratory failure status post mechanical fall." A Neurosurgical Consultation (brain specialist) report, dated 9/29/15, indicated that Patient 1 was diagnosed with an acute subdural hematoma (bleeding within the brain).

During an interview and record/document review on 10/13/15 at 11:00 A.M., the DQM acknowledged that Patient 1's safety had not been maintained when the patient's risk for falls had not been assessed per the hospital's policy and procedure on the shift of a fall occurrence. The DQM acknowledged that the patient's bed exit alarm, which had been identified as a care plan fall prevention intervention, had not been implemented at the time of the patient's fall. In addition, the DQM acknowledged policies and procedures for nursing assessment and care planning and post fall nursing care had not been implemented as planned. In addition, the DQM acknowledged that the hospital post fall policy and procedure were not specific and post fall assessments were not conducted in a manner that met the needs of a patient who had sustained a witnessed fall and head injury.

Based on interview and record/document review the hospital failed to ensure that contracted licensed nurses adhered to the hospital's policies and procedures related to fall prevention assessments, care plan implementation and documentation for 1 of 30 sampled patients (1). Patient 1 was assigned to a contracted licensed nurse who did not perform a fall risk assessment in accordance with the approved assessment tool identified in the fall prevention policy. In addition, the contracted licensed nurse failed to implement Patient 1's care plan interventions for fall prevention.

Findings:

Patient 1 was admitted to the hospital (long term acute care hospital) on 9/16/15 with diagnoses which included multiple skin abscesses (infected skin wounds) and hepatic encephalopathy (a metabolic brain disorder which can occur in advanced liver disease and cause impaired memory and intellectual function) per the physician's Admission History and Physical Examination document dated 9/16/15. The same document included that Patient 1 was on deep venous thrombosis prophylaxes (an anticoagulant medication regime used to slow blood clotting time and decrease blood clot formation).

During an interview on 10/6/15 at 1:00 P.M., the Director of Quality Management (DQM) stated that Patient 1 sustained a witnessed fall on the morning of 9/29/15, while the patient was in the hospital. The DQM stated that Patient 1 developed a change of condition after the fall and had been transferred to another Hospital (B - general acute care hospital) for emergency services on the day of the fall. The DQM stated Hospital B had informed them of the patient's death on 10/2/15.

During an interview and joint record/document review on 10/6/15 at 2:00 P.M., Medical Doctor (MD) 1 stated that he was on day shift duty 9/29/15 and responded to Patient 1's room when called by nursing staff. MD 1 stated he was informed by the nursing staff that Patient 1 had sustained a fall "about an hour ago". MD 1 stated he examined the patient and observed a "boggy hematoma" (an abnormal soft formation of blood outside of a blood vessel) on the back of the patient's head. A review of MD 1's Chart Note, dated 9/29/15 at 8:19 A.M., described the hematoma as "R (right) occipital (lower back of the head) scalp... large...6 x 8 cm (centimeters) in size..." MD 1 stated the patient was non verbal, unresponsive to pain, had a decreased level of conscious and that the patient's eye pupils were "poorly responsive" (a symptom of impaired brain function). The same Chart Note included that Patient 1 had been administered a 10 mg (milligram) dose of Ambien (a sedative medication with potential side effects which can induce forgetfulness and impaired judgement/physical function) on the night shift of the fall occurrence. MD 1 stated that he instructed the hospital staff to call 911 for emergency transport.

During an interview on 10/6/15 at 3:00 P.M., the DQM stated that "all" of the hospital patient beds have the built in capability to be alarmed to detect exit from the bed. The DQM stated that the alarm function can be turned turned on or off manually. The DQM stated that hospitalized patients that were assessed at high risk risk for falls should have "full" fall prevention interventions in place, which would include an engaged bed exit alarm. The DQM stated that Patient 1 had been previously assessed as a high fall risk and at the time of the fall, the patient's bed exit alarm was not turned on. The DQM stated that the hospital licensed nursing staff were responsible for the assessment of assigned patients on each shift (7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M.) The DQM stated the hospital used the Modified Morse Fall Scale (an assessment tool which assigns a numerical value to various patient characteristics and identifies a risk for falls based on a total score). The DQM stated that the Modified Morse Fall Scale was imbedded in the hospital electronic medical record document and was available for use by the "regular" nursing staff and "some" contract temporary nurses. The DQM stated that a paper version, of the same Modified Morse Fall Scale, had not been made available to licensed nurses unable to access the assessment tool in the electronic medical record. The DQM stated that Patient 1 was assigned to the care of a contract temporary nurse on the shift of the patient's fall occurrence. The DQM stated that the contract nurse "was not cleared for access to the hospital electronic medical record."

A review of the hospital's electronic Patient Assessment Report document, dated 9/28/15 at 7:30 A.M., indicated an assessment of Patient 1's physical status. The same report included the "Morse Fall Risk" assessment and identified "Morse Fall Scale Total 50.00". The Morse Fall Risk assessment tool identifies total numerical scores of 45 or greater as a high risk for falls. There was no evidence of Patient 1's Morse Fall Scale assessment for the 9/28/15 7:00 P.M. to 7:00 A.M. shift.

During an interview and joint record/document review on 10/7/15 at 10:15 A.M., RN 2 stated that he was a contracted temporary licensed nurse and had been assigned as Patient 1's primary nurse on the shift of the patient's fall occurrence. RN 2 stated that he had worked at the hospital on several other shifts over the course of the past year. RN 2 stated that he had completed the hospital "online training" however, RN 2 stated that the hospital's fall policies and procedures "were not specifically included in the orientation." RN 2 stated that he received a verbal report of the patient's status, however the patient's fall risk status was not discussed. RN 2 stated " I thought the patient was at moderate risk for falls" however, RN 2 acknowledged that he had not used the Modified Morse Fall Scale to make that assessment. RN 2 stated that he used a paper version of an assessment tool, which did not include the Modified Morse Fall Scale. RN 2 added that Patient 1 was oriented and "I'm not in the habit of alarming the beds of oriented patients." RN 2 stated that he did not have access to the patient's electronic record for use of the assessment tools or viewing of patient care plan interventions. RN 2 stated that he was in Patient 1's room at the time of the fall occurrence. RN 2 stated that a bed alarm did not sound, but he noticed Patient 1 had exited his bed and entered an adjacent toilet area. RN 2 stated that he then witnessed Patient 1 fall "over backwards" from the toilet area directly to the floor with a "loud thump" and struck his head. RN 2 stated that nursing and medical staff responded to a call for assistance and he reported that the patient had "hit hard". RN 2 stated that a responding medical doctor had gave directions, which included "monitor the patient", however the specific monitoring and frequency parameters were not identified, clarified or ordered. RN 2 stated that he performed 2 blood pressure measurements and "neuro checks (eye pupil response)" between 6:55 A.M. and 7:00 A.M. and "more later". RN 2 stated at 7:40 A.M., he returned to assess Patient 1 and found the patient unable to respond verbally and with a decreased level of consciousness. A joint review of the paper version Medical/Surgical Flowsheet assessment, dated "9/28/15 PM", revealed no documentation of ongoing patient blood pressure measurements or neuro checks from 7:00 A.M. until 7:40 A.M. In addition, a review of Patient 1's Neurological Assessment Flow Sheet form, dated 9/29/15, revealed no documentation of patient assessments between 7:00 A.M. and 7:40 A.M. Furthermore, a review of the hospital Rapid Response Team Record form for Patient 1, indicated that the "Assessment" and "Reassessment" areas of the form had been completed as a "late entry" on 9/30/15 during the timeframe of 4:50 P.M. to 5:00 P.M. RN 2 stated he was not familiar with the hospital expectations for post fall assessments. RN 2 had no explanation for his incomplete and un-timely documentation of the fall occurrence.

During an interview on 10/7/15 at 11:30 A.M., RN 3 stated that she was a shift nursing supervisor and responded to the call for assistance in Patient 1's room on the day of the fall occurrence. RN 3 stated that she heard Medical Doctor (MD) 3 give an order for a head CAT scan (computerized axial tomography special radiology test to image disease or injury) and began to make arrangements for the procedure. RN 3 stated the hospital did not have a "fall protocol". However, RN 3 stated the hospital's policy and procedure related to falls, included every 30 minute assessment of post fall neuro checks and vital signs (assessment of blood pressure, pulse, respirations, pain). RN 3 stated that RN 2 was a contracted temporary nurse and did not have access to the patient's electronic record. RN 3 stated that RN 2 had "questions" about hospital forms and monitoring, after the patient's fall. RN 3 did not assess the patient or RN 2's documentation until after the patient had a change of condition and the patient was transferred via 911. RN 3 stated "later in the shift" she discovered that RN 2's documentation of the fall occurrence and the rapid response code after the fall had not been documented in Patient 1's paper version or electronic medical record.

A review of Patient 1's care plan, dated 9/17/15, identified the ongoing problem "FALL AND INJURY RISK" and the objective "FREE FROM FALL AND INJURY". The interventions included "BED EXIT ALARM...LOW BED...YELLOW ARMBAND". In addition, the care plan identified the problem "ALTERED MOBILITY" with interventions that included "ASSIST WITH ADLS (activities of daily living)".

A review of the hospital policy and procedure, revision dated "12/14", included "All patients admitted to the inpatient setting will be assessed for fall "risk" using the Modified Morse Fall Risk on admission, each shift...Safety devices will be initiated when indicated according to policy as soon as possible once the patient is assessed as being "at risk" for falling...Fall Risk Assessment: If any of these medical factors are present the patient may be at "risk" for falls...infection, toxic/metabolic...sleep disturbances...Meds...anticoagulant...Impaired mobility...Standard Fall Prevention Interventions:Assess patient's fall risk...each shift...High Risk Fall Prevention Interventions:These interventions are designed to be implemented for patients with multiple fall risk factors... Use for those who score High Risk on the Fall Risk Assessment (>45 on Modified Morse Fall Risk Assessment)...Consider use of safety technology for fall prevention...Yellow wristband...Bed and chair alarm...Assessment of the patient post fall: Obtain vital signs and neuro checks when appropriate..."

During a Quality Assurance and Performance Improvement committee interview on 10/13/15 at 1:00 P.M., the DQM stated that RN 2 had worked several shifts at the hospital prior to 9/28/15. The DQM identified the most recent shifts of August 9, 15, 16, 23, 30 and September 12 and 28. The DQM acknowledged that RN 2 had not yet been given "clearance" for access to the hospital electronic record and assessment tools.

During an interview and joint record/document review on 10/7/15 at 2:00 P.M., the DQM stated that Patient 1 had been assessed at high risk for fall on the shift prior to the fall occurrence per the Modified Morse Risk Scale and that an assessment had not occurred on the shift of the fall occurrence. The DQM stated that the patient care plan had identified the need for a bed exit alarm and acknowledged that the bed exit alarm had not been implemented at the time of the patient fall.

Based on interview and record/document review the hospital failed to maintain medical records as required for 1 of 30 sampled patients (1). Licensed nurse narrative notes, which described a fall occurrence, were not entered into Patient 1's medical record in a timely manner. In addition, the same notes were not timed to reflect the actual times of patient observations. Furthermore, a nursing form used to document an emergency response for the patient, was not completed in a timely manner. Nursing documentation of the patient's nursing notes and emergency fall occurrence response was not available for review until 1 day after the actual occurrence.

Findings:

Patient 1 was admitted to the hospital (long term care hospital) on 9/16/15 with diagnoses which included multiple skin abscesses (infected skin wounds) and hepatic encephalopathy (a metabolic brain disorder which can occur in advanced liver disease and cause impaired memory and intellectual function) per the physician's Admission History and Physical Examination document dated 9/16/15. The same document included that Patient 1 was on deep venous thrombosis prophylaxes (an anticoagulant medication regime used to slow blood clotting time and decrease blood clot formation).

During an interview on 10/6/15 at 1:00 P.M., the Director of Quality Management (DQM) stated that Patient 1 sustained a witnessed fall on the morning of 9/29/15, while the patient was in the hospital. The DQM stated that Patient 1 developed a change of condition after the fall and had been transferred to another hospital (B a general acute care hospital) for emergency services on the day of the fall. The DQM stated hospital B had informed them of the patient's death on 10/2/15.

During an interview and joint record/document review on 10/6/15 at 2:00 P.M., Medical Doctor (MD) 1 stated that he was on day shift duty 9/29/15 and responded to Patient 1's room when called by the nursing staff. MD 1 stated he was informed by the nursing staff that Patient 1 had sustained a fall "about an hour ago". MD 1 stated he examined the patient and observed a "boggy hematoma" (an abnormal soft formation of blood outside of a blood vessel) on the back of the patient's head. A review of MD 1's Chart Note, dated 9/29/15 at 8:19 A.M., described the hematoma as "R (right) occipital (lower back of the head) scalp... large...6 x 8 cm (centimeters) in size..." MD 1 stated the patient was non verbal, unresponsive to pain, had a decreased level of conscious and that the patient's eye pupils were "poorly responsive" (a symptom of impaired brain function). MD 1 stated that he instructed the hospital staff to call 911 for emergency transport.

During an interview on 10/6/15 at 3:00 P.M., the DQM stated that the hospital licensed nursing staff were responsible for the assessment of assigned patients on each shift (7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M.) The DQM stated the hospital used the Modified Morse Fall Scale (an assessment tool which assigns a numerical value to various patient characteristics and identifies a risk for falls based on a total score). The DQM stated that the Modified Morse Fall Scale was imbedded in the hospital electronic medical record document and was available for use by the "regular" nursing staff and "some" contract temporary nurses. The DQM stated that a paper version, of the same Modified Morse Fall Scale, had not been made available to licensed nurses unable to access the assessment tool in the electronic medical record. The DQM stated that Patient 1 was assigned to the care of a contract temporary nurse on the shift of the patient's fall occurrence. The DQM stated that the contract nurse "was not cleared for access the hospital electronic record."

A review of the hospital's electronic Patient Assessment Report document, dated 9/28/15 at 7:30 A.M., indicated an assessment of Patient 1's physical status. The same report included the "Morse Fall Risk" assessment and identified "Morse Fall Scale Total 50.00". The Morse Fall Risk assessment tool identifies total numerical scores of 45 or greater as a high risk for falls. There was no evidence of Patient 1's Morse Fall Scale assessment for the 9/28/15 7:00 P.M. to 7:00 A.M. shift.

During an interview and joint record/document review on 10/7/15 at 10:15 A.M., RN 2 stated that he was a contracted temporary licensed nurse and had been assigned as Patient 1's primary nurse on the shift of the patient's fall occurrence. RN 2 stated that he had worked at the hospital on several other shifts over the course of the past year. RN 2 stated that he had completed the hospital "online training" however, RN 2 stated that the hospital's fall policies and procedures "were not specifically included in the orientation." RN 2 stated that he received a verbal report of the patient's status, however the patient's fall risk status was not discussed. RN 2 stated " I thought the patient was at moderate risk for falls" however, RN 2 acknowledged that he had not used the Modified Morse Fall Scale to make that assessment. RN 2 stated that he used a paper version of an assessment tool, which did not include the Modified Morse Fall Scale. RN 2 added that Patient 1 was oriented and "I'm not in the habit of alarming the beds of oriented patients." RN 2 stated that he did not have access to the patient's electronic record for use of the assessment tools or viewing of patient care plan interventions. RN 2 stated that he witnessed Patient 1 fall "over backwards" from the toilet area directly to the floor with a "loud thump" and struck his head. RN 2 stated that nursing and medical staff responded to a call for assistance and he reported that the patient had "hit hard". RN 2 stated that a responding medical doctor had gave directions, which included "monitor the patient", however the specific monitoring and frequency parameters were not identified, clarified or ordered. RN 2 stated that he performed 2 blood pressure measurements and "neuro checks (eye pupil response)" between 6:55 A.M. and 7:00 A.M. and "more later". RN 2 stated at 7:40 A.M., he returned to assess Patient 1 and found the patient unable to respond verbally and with a decreased level of consciousness. A joint review of the paper version Medical/Surgical Flowsheet assessment, dated "9/28/15 PM", revealed no documentation of ongoing patient blood pressure measurements or neuro checks from 7:00 A.M. until 7:40 A.M. In addition, a review of Patient 1's Neurological Assessment Flow Sheet form, dated 9/29/15, revealed no documentation of patient assessments between 7:00 A.M. and 7:40 A.M. Furthermore, a review of Patient 1's hospital Rapid Response Team Record form indicated that the "Assessment" and "Reassessment" areas of the form had been completed as a "late entry" on 9/30/15 during the timeframe of 4:50 P.M. to 5:00 P.M. RN 2 stated he was not familiar with the hospital expectations for post fall assessments. RN 2 had no explanation for his incomplete and un-timely documentation of the fall occurrence.

During an interview on 10/7/15 at 11:30 A.M., RN 3 stated that she was a shift nursing supervisor and responded to the call for assistance in Patient 1's room on the day of the fall occurrence. RN 3 stated the hospital did not have a "fall protocol". However, RN 3 stated the hospital's policy and procedure related to falls, included every 30 minute assessment of post fall neuro checks and vital signs (assessment of blood pressure, pulse, respirations, pain). RN 3 stated that RN 2 was a contracted temporary licensed nurse and did not have access to the patient's electronic record. RN 3 stated that RN 2 had "questions" about hospital forms and monitoring, after the patient's fall. RN 3 did not assess the patient or RN 2's documentation until after the patient had a change of condition and the patient was transferred via 911. RN 3 stated "later in the shift" she discovered that RN 2's documentation of the fall occurrence and the rapid response code after the fall had not been documented in Patient 1's paper version or electronic medical record.

A review of the hospital policy and procedure, dated "12/14", included "Assessment of the patient post fall: Obtain vital signs and neuro checks when appropriate...".

A review of the hospital entitled Nursing Planning, dated "5/14" included "It communicates pertinent patient problems/needs, delineates appropriate medical and nursing interventions to meet these needs, and documents the effectiveness of the interventions in the medical record." and "Documentation of the Plan of Care: The licensed nurse will document at least once a shift in the nursing note about the plan of care and the patient's response to the plan. The nurse will document interventions and care given to address the patient's problem list and to meet the identified needs of the patient as well as the effectiveness of those interventions noted in the plan of care."

During an interview and joint record/document review on 10/7/15 at 2:00 P.M., the DQM acknowledged that Patient 1's medical record had not been maintained as expected and required when documentation of Patient 1's fall occurrence and rapid response code had not been performed in a timely or complete manner when the contracted nurse left the hospital without completion of the documentation and post nursing care of the patient's fall occurrence.