Southwell Medical, A Campus of Trmc

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 49224 Based on video recordings, medical record review, staff interview, facility policies and procedures, and facility video surveillance footage, it was determined that the facility failed to reasonably prevent one patient (P) (P#1) from encountering a fall. Findings include: A facility unit surveillance video footage recorded on 8/13/24 with a time stamped from 8:07:56 p.m. to 8:10:07 p.m. revealed the following: “ 8:07:56 p.m. - P#1 sat in a roller recliner chair (RRC) with a rollator walker directly in from of her in the dayroom. “ 8:08:34 p.m. - P#1 placed both hands on the arm rests of the RRC. “ 8:08:36 p.m. - P#1 stood up from the RRC and the chair proceeded to roll away from P#1’s body. “ 8:08:37 p.m. - The RRC continued to roll away from P#1’s body and P#1 proceeded to fall to the floor. “ 8:08:37 p.m. - P#1 fell to the floor and landed bottom first, then the left side of the body, and the left side of her head. “ 8:08:38 p.m. - Blue Scrub Staffer 1 (BSS1) looks over to P#1 on the floor. “ 8:08:39 p.m. - P#1 lifts head from floor. “ 8:08:40 p.m. -BSS proceeded through the nurse’s station gate towards P#1. “ 8:08:45 p.m. - BSS assisted P#1 into a sitting position on the floor. “ 8:08:47 p.m. - Green Scrub Staffer (GSS) came over to help “ 8:09:26 p.m. - BSS 2 came over to help. “ 8:09:41 p.m. - BSS1, BSS2, and GSS all lifted P#1 from the floor. “ 8:09:50 p.m. - P#1 was assisted to the rollator walker “ 8:09:59 - P#1 was assisted with walking to another area of the unit. A review of facility policy titled “Patient Rights and Responsibilities,” effective 2/16/24, revealed that in the case of a patient who has cognitive impairments, the Facility employee would provide information on the patient’s rights and responsibilities to the patient’s representative and or legal representative. Each patient of Tift Regional Health System (TRHS) was entitled to certain rights and assumed certain responsibilities. Each patient had the right to expect reasonable safety while receiving care and services. A review of facility policy titled “Falls Risk-Inpatient,” effective 2/22/21, revealed that “fall” means a patient fall, assisted patient fall, and suspected intentional fall. Adult patients admitted to a facility will be assessed for fall risk on admission and once every twelve hours using the Morse Fall Risk Assessment Scale. If a fall occurs or is suspected (1) an assessment for injury will occur, (2) notification to House Supervisor and patient’s family, (3) actions following a fall should include: (a) Reclassification of the patient as a high risk for falls and implementation of additional fall risk interventions, (b) Completion of an occurrence report/patient safety event report in compliance with the hospital policy entitled, “Patient Occurrence - Patient Safety Event Reporting”, (c) House Supervisor should come to the unit and debrief the staff involved and will verify that an occurrence report/patient safety event report was completed and the fall is documented in the patient’s medical record. A review of facility policy titled “Patient Assessment and Care Plan,” effective 6/3/24, revealed that an RN completes a basic nursing physical assessment and initiates the plan of care within the first twelve hours following the hospital admission. The scope and content of the nursing admission assessment included components and screenings of the physical, psychological, social, spiritual, cultural, educational, functional, nutritional, developmental/age-appropriate, and post-hospitalized assistance needs of the patient, as appropriate and relevant to care, treatment, and services to be provided during the hospital encounter. All patient assessment and reassessment data is recorded in the patient’s medical record in a format determined by each discipline and approved, when appropriate, by the Forms Committee. Inpatient reassessment occurs at least once per shift and as indicated by changes in the patient’s response to care, treatment, and services. A telephone interview was conducted with Registered Nurse (RN) GG on 9/4/24 at 10:58 a.m. RN GG stated that she worked as the Charge Nurse on the Geri-psyche unit on the night shift. She said P#1’s first night with her was on the twelfth (8/12/24) and that she had a black eye and some sores on her legs. RN GG stated that she never spoke with P#1’s family, and that she had been told in report that P#1 had fallen at home. When RN GG was asked if she ever witnessed P#1 fall in the unit, RN GG stated that P#1 slid to the floor from her chair, and that she helped one of the techs get P#1 up from the floor and to the restroom. RN GG stated that she didn’t notify the doctor or the family about this occurrence because P#1 didn’t sustain an injury, and that P#1 fell often at home. RN GG stated that when a patient fell, the occurrence should be reported to the doctor and the family, and an incident report recorded.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 49224 Based on medical record review, staff interviews, facility policies and procedures, and facility video surveillance footage, it was determined that the facility failed to notify physician and the patient’s family for two patients (P) (P#1, P#3) following a fall. Findings include: 1. A medical record review for P#1 failed to reveal that P#1’s doctor and P#1’s family was notified following a fall. 2. A medical record review for P#3 failed to reveal that P#13’s doctor and P#13’s family was notified following a fall. A review of a facility policy titled “Patient Rights and Responsibilities,” effective 2/16/24, revealed that in the case of a patient who has cognitive impairments, the Facility employee would provide information on the patient’s rights and responsibilities to the patient’s representative and or legal representative. Each patient of Tift Regional Health System (TRHS) was entitled to certain rights and assumed certain responsibilities. Each patient had the right to expect reasonable safety while receiving care and services. A review of a facility policy titled “Falls Risk-Inpatient,” effective 2/22/21, revealed that “fall” means a patient fall, assisted patient fall, and suspected intentional fall. Adult patients admitted to a facility will be assessed for fall risk on admission and once every twelve hours using the Morse Fall Risk Assessment Scale. If a fall occurs or is suspected (1) an assessment for injury will occur, (2) notification to House Supervisor and patient’s family, (3) actions following a fall should include: (a) Reclassification of the patient as a high risk for falls and implementation of additional fall risk interventions, (b) Completion of an occurrence report/patient safety event report in compliance with the hospital policy entitled, “Patient Occurrence - Patient Safety Event Reporting”, (c) House Supervisor should come to the unit and debrief the staff involved and will verify that an occurrence report/patient safety event report was completed and the fall is documented in the patient’s medical record. An interview was conducted with Director of Nursing (DON) KK on 9/3/24 at 3:30 p.m. DON KK stated that she didn’t see in P#3’s medical record where it was documented that P#3’s family was notified that he had fallen again. She stated that the expectation was that nurses should document what they do for the patient into the patient’s medical record. An interview was conducted with Registered Nurse (RN) FF on 9/4/24 at 10:14 a.m. RN FF stated that when a patient fell, an assessment was conducted immediately for injury, the doctor and family were notified, and an incident report was recorded. A telephone interview was conducted with RN GG on 9/4/24 at 10:58 a.m. RN GG stated that she worked as the Charge Nurse on the Geri-psyche unit on the night shift. She said P#1’s first night with her was on the twelfth (8/12/24) and that she had a black eye and some sores on her legs. RN GG stated that she never spoke with P#1’s family, and that she had been told in report that P#1 had fallen at home. When RN GG was asked if she ever witnessed P#1 fall in the unit, RN GG stated that P#1 slid to the floor from her chair, and that she helped one of the techs get P#1 up from the floor and to the restroom. RN GG stated that she didn’t notify the doctor or the family about this occurrence because P#1 didn’t sustain an injury, and that P#1 fell often at home. RN GG stated that when a patient fell, the occurrence should be reported to the doctor and the family, and an incident report recorded. A telephone interview was conducted with RN JJ on 9/4/24 at 1:11 p.m. RN JJ stated that she worked as one of the Charge Nurses on the unit. RN JJ stated that generally, when a fall occurred, the patient was assessed, the doctor and family were notified, an occurrence report would be recorded, and the nurse would complete a narrative note with the action details.”