Rehabilitation Hospital of Overland Park

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 40633 Based on observation, interview, and review of the Hospital’s Emergency Preparedness Plan, the Hospital failed to ensure a comprehensive and coordinated sheltering plan was in place for tornado warnings, as required. Specifically, the facility’s emergency preparedness policy did not include detailed procedures for tornado events, lacked a clear and organized sheltering location, and did not ensure staff training or communication protocols to respond effectively in the event of a tornado warning. As a result, the facility’s failure to implement appropriate sheltering measures directly affects all 45 patients, staff, and visitors across all 4 of 4 smoke zones. This lack of preparedness puts everyone within the facility at significant risk during a tornado emergency, compromising their safety and well-being during such critical situations. Findings Include: On June 3, 2025, during a tornado warning issued at 2:07 PM and cleared at 2:47 PM, the facility had only patient rooms identified as sheltering areas in its emergency preparedness plan. This is not consistent with the guidance that recommends more specific and secure shelter locations. The sheltering area observed was disorganized and lacked clear instructions for staff and patients. No audible announcement was made regarding the tornado warning inside the facility, despite a city tornado siren being heard at 2:16 PM. Staff did not come to check on the surveyor, indicating a breakdown in the communication process and lack of a structured response to tornado warnings. Interviews with staff on June 5, 2025, revealed that they were unaware of the facility’s procedures for tornado warnings or watches. This lack of awareness violates the regulatory requirement for staff training and awareness as part of a unified emergency preparedness program. The facility’s emergency preparedness plan lacked specific consideration of tornadoes, particularly regarding sheltering procedures for patients, staff, and visitors. This oversight fails to comply with §416.54 and the interpretive guidelines, which require an all-hazards approach to risk assessment and emergency planning. The CEO and Director of Plant Operations were present and acknowledged the findings.”

“Building Rehabilitation CFR(s): NFPA 101 Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: * Requirements of Chapter 18 and 19 * Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 Change of Use or Change of Occupancy Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2 18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8. 18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8) This Standard is not met as evidenced by: 40633 Based on observation, document review, and policy review, the hospital failed to meet the applicable provisions of the current LSC requirements under the National Fire Protection Association (NFPA) 101, Section 19.1.1.3.2 and NFPA 101, Section 19.1.1.1.5. The cumulative effect of this deficient practice has the potential to place any patient, staff or visitor at the hospital at risk for serious injury, serious harm, serious impairment or death. Findings Include: The facility failed to ensure that the building’s rehabilitation work was conducted in compliance with NFPA 101, 2012 Edition, particularly with regard to the fire safety provisions required during repair, renovation, modification, or reconstruction. Specifically, the lack of a Fire Watch and failure to properly manage water damage repairs, which involved the removal of ceiling tiles and placement of items in the corridor to collect and dry water, created significant fire hazards and jeopardized the safety of all occupants, visitors, and staff, including 14 patients who were moved to the south wing of the first floor on February 13, 2025. During a document review and interviews on 6/5/25 it was observed: 1. Failure to Implement Fire Watch: During the repair activities to address water leaks on the first floor (February 13, 2025, through February 18, 2025), the facility did not initiate a Fire Watch despite removing ceiling tiles in nine areas and placing items in corridors to collect and dry the water. NFPA 101, Section 19.1.1.3.2, requires fire prevention measures and adequate maintenance of safety procedures during building repairs. The lack of a Fire Watch compromised the ability to monitor and manage fire risks in these areas affecting the entire hospital emergency response of fire alarm and fire sprinkler system. 2. Inadequate Control of Sprinkler System During Rehabilitation: The facility did not ensure that the sprinkler heads were turned to deck during the rehabilitation of the water-damaged areas. As outlined in NFPA 101, Section 19.3.5.3, health care facilities must maintain fully functional automatic sprinkler systems, which was not the case in this instance, exposing the facility to increased fire risks, especially in high-occupancy areas such as patient rooms. 3. Occupancy of Evacuated Patients in Unprotected Areas: On February 13, 2025, 14 patients were relocated to the south wing of the first floor after being evacuated from the second floor. This relocation occurred while repairs were ongoing, and no temporary fire safety measures were implemented in the affected areas. These actions violated Section 19.1.1.1.5 and 19.1.1.3.2, which emphasize the need for a high degree of safety and fire protection for health care occupancies, especially when patients who are unable to self-preserve are involved. 4.Failure to Ensure Full Compliance During Rehabilitation Work: The repair and renovation activities, as per NFPA 101, Section 4.6.7, must meet the requirements of Chapter 43 for rehabilitation work. However, the failure to implement fire safety protocols, such as Fire Watch and proper sprinkler system adjustments, indicated non-compliance with the safety standards necessary for health care facilities undergoing renovations. The CEO and Director of Plant Operations were present and acknowledged the findings. Reference: NFPA 101, 2012 Edition, Section 4.6 (General Requirements) NFPA 101, 2012 Edition, Section 19.1.1.1.5 (Health Care Facilities) NFPA 101, 2012 Edition, Section 19.1.1.3.2 (Fire Prevention and Safety Procedures) NFPA 101, 2012 Edition, Section 19.3.5.3 (Sprinkler System Requirements) NFPA 101, 2012 Edition, Section 19.3.4.1 (Detection and Alarm Systems) NFPA 101, 2012 Edition, Section 4.6.7 (Rehabilitation Work Compliance)”

“SPRINKLER SYSTEM CFR(s): (8) When a sprinkler system is shut down for more than 10 hours, the hospital must: (i) Evacuate the building or portion of the building affected by the system outage until the system is back in service, or (ii) Establish a fire watch until the system is back in service. This Standard is not met as evidenced by: 47233 Based on policy review, document review and interview, the hospital failed to implement fire safety measures during the rehabilitation work, including the lack of a Fire Watch and failure to properly manage sprinkler system functionality. (Refer to LSC Tag K-111) Findings Include: During a document review and interviews on 6/5/25 it was observed: 1. Failure to Implement Fire Watch: During the repair activities to address water leaks on the first floor (February 13, 2025, through February 18, 2025), the facility did not initiate a Fire Watch despite removing ceiling tiles in nine areas and placing items in corridors to collect and dry the water. The National Fire Protection Association (NFPA) 101, Section 19.1.1.3.2, requires fire prevention measures and adequate maintenance of safety procedures during building repairs. The lack of a Fire Watch compromised the ability to monitor and manage fire risks in these areas affecting the entire hospital emergency response of fire alarm and fire sprinkler system. 2. Inadequate Control of Sprinkler System During Rehabilitation: The facility did not ensure that the sprinkler heads were turned to deck during the rehabilitation of the water-damaged areas. As outlined in NFPA 101, Section 19.1.1.3.2, health care facilities must maintain fully functional automatic sprinkler systems, which was not the case in this instance, exposing the facility to increased fire risks, especially in high-occupancy areas such as patient rooms. 3. Occupancy of Evacuated Patients in Unprotected Areas: On February 13, 2025, 14 patients were relocated to the south wing of the first floor after being evacuated from the second floor. This relocation occurred while repairs were ongoing, and no temporary fire safety measures were implemented in the affected areas. These actions violated NFPA 101, Section 19.1.1.1.5 and 19.1.1.3.2, which emphasize the need for a high degree of safety and fire protection for health care occupancies, especially when patients who are unable to self-preserve are involved. 4.Failure to Ensure Full Compliance During Rehabilitation Work: The repair and renovation activities, as per NFPA 101, Section 4.6.7, must meet the requirements of Chapter 43 for rehabilitation work. However, the failure to implement fire safety protocols, such as Fire Watch and proper sprinkler system adjustments, indicated non-compliance with the safety standards necessary for health care facilities undergoing renovations. The CEO and Director of Plant Operations were present and acknowledged the findings.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 47233 Based on record review, document review, policy review, and interview, the hospital failed to re-evaluate a patient for discharge that had a critical lab result for 1 of 8 (Patient 3) patients reviewed. This deficient practice has the potential to negatively impact the health and well-being of any patient receiving care in this hospital and could result in rehospitalizations. Findings Include: Review of a hospital policy titled, “Discharge Planning” reviewed 01/15/24 showed, “ ...[The Hospital] provides an interdisciplinary collaborative discharge planning process focusing on the individualized goals and treatment preferences of the patient to ensure an effective transition of the patient from hospital to post-discharge care, and reduce potential factors leading to a preventable hospital readmission. Collaborative communication in discharge planning is a shared responsibility of the interdisciplinary healthcare team, patient, and designated patient support caregiver. The discharge planning process will be coordinated by the Case Manager in collaboration with patient, designated patient support caregiver, physician and other members of the interdisciplinary healthcare team to ensure joint communication and problem-solving for optimal outcomes with respect to patient preferences and available resources. Patients will be discharged based upon attainment of the patient care goals as evident in the interdisciplinary plan of care ... L. The Case Manager will secure acceptance for post discharge hospital services as applicable to the discharge plan of care. Documentation should include details of acceptance of the service/provider, and information shared to obtain acceptance for post-discharge care needs. M. The Case Manager will confirm and/or assist with the arrangements for the following, but not limited to in preparation of discharge: 1. Essential durable medical equipment and supplies ordered/delivered; 2. Post-discharge follow-up appointments with primary providers and/or specialist(s)scheduled and necessary medical information received; 3. Secure transportation with community-based resources as appropriate for patient needs if family unable to provide; 4. Secure community-based resources as applicable (medication assistance; waiver programs; senior housing, etc.) 5. Arrange for outpatient services such as dialysis, infusions, outpatient therapies, and Coumadin clinics as applicable ...” Patient 3 Review of Patient 3’s medical record showed a 70-year-old admitted on 02/07/25 with a diagnosis of other specified myopathies (diseases that affect skeletal muscles, leading to muscle weakness and dysfunction). Past medical history included hypertension (elevated blood pressure), depression, chronic obstructive pulmonary disease, and dementia. Review of a document titled, “Interdisciplinary Patient Care Conference Report,” dated 02/11/25 at 11:31 AM, showed, “ ...Discharge Planning Needs ...1. Patient will be discharged to an appropriate level of care or setting to meet the patient needs. 2. Patient will have adequate equipment and supplies for maintenance of care at home. Interventions/Education: ...5. Arrange for after care in the appropriate level. 6. Facilitate obtaining necessary equipment and supplies to ensure continued care after discharge ... What is the overall expected length of stay for this patient? 7-10 days ...” Review of a document titled, “Care Plan Notes,” dated 02/11/25 at 2:43 PM, showed, “ ...Observation: CM [case management] met with the pt [patient] following the IDT [Interdisciplinary Team] meeting on 2/11. Pt met with the DC [discharge] date and plan in place from the meeting ...” Review of a document titled, “Notes,” signed by Nurse Practitioner (NP) dated 02/13/25 at 6:11 PM, showed, “ ...He was found to have high potassium and his potassium was HELD. He was given Lokelma [medication for high potassium] and had planned for re-check tomorrow 2/14 [02/14/25]. a pipe bursted [sic] and several patients were needed to be re-located and/or discharge. Without the knowledge of the medical team, this patient was discharged home with home health. This patient was not ready for discharge as he was still being worked-up for hyperkalemia [condition of abnormally high levels of potassium in the blood that can lead to abnormal heart rhythms, muscle weakness and/or paralysis, heart attack and/or sudden cardiac arrest]. The patient needs to get his labs drawn tomorrow or go to the ER [emergency room] ... Discharge Condition & Disposition: NOT ready for discharge home with home health ...” Review of an incident report dated 02/13/25 showed, “ ...Patient was discharged today. CM [case management] verbally told me that patient would discharge. [The Hospital] transport took patient home. Patient left without any discharge instructions ...Message sent to APRN [Advanced Practice Registered Nurse] to notify of discharge. APRN states she did not approve of discharge and that patient had a critical high potassium of 5.7 and needs labs rechecked ... At approx. [approximately] 1015am [10:15 AM], the 1st floor of the hospital where [Patient 3] was located had an unexpected incident causing evacuation of the nursing unit to the cafe and upstairs. Multiple coils in the heating system froze overnight due to negative temperatures outside which then caused the coils to break and multiple water leaks throughout the first floor. At the time of the incident, we were unclear what the issue was and due to the hospital being full, we attempted to discharge patients who were upcoming in the next few days and who had support at home for safety. The DCM [director of case management] and CM [case management] team discussed moving discharges ...and determined that [Patient 3] could potentially move from 2.15.25 to today, 2.13.25 ...received a text message from ...NP ...”why was a patient discharged without our knowledge ...He was not a safe discharge. He had an elevated potassium of 5.7 yesterday that was being treated and we were going to repeat labs tomorrow. If he’s home he needs to go to the ER to get that checked ...” During an interview on 06/03/25 at 12:44 PM, Staff F, Social Worker, stated that staff were instructed to discharge any patient from the 1st floor that was close to discharge. During an interview on 06/04/25 at 9:02 AM Staff D, Director of Case Management stated that on 02/13/25 leadership gave instructions to discharge any patient that was discharging either that day or within 48 hours.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 47233 Based on observation and interview, the hospital failed to protect patients’ health information by leaving medical record information readily available for anyone entering the hospital to see for three observations on 10/30/24. Findings Include: Review of a hospital policy titled, “Patient Rights and Responsibilities” Revised 10/21/24 showed, “ ...1. Every patient admitted to a [The Hospital] hospital is given a written copy of the Patient’s Bill of Rights prior to admission, and, within 24 hours of admission, each patient is given an explanation of his/her rights and responsibilities as a patient. 2. The hospital will provide an explanation of the patient’s rights and responsibilities in the patient’s primary language, if requested. 3. The hospital shall obtain a signed copy of the Patient’s Bill of Rights from each patient or patient’s family, if appropriate. The signed copy shall include a statement that the patient and or patient’s family has read the document and understands the rights specified in the document. 4. The hospital shall retain a signed copy of the Patient’s Bill of Rights in the patients’ medical file. 5. The [The Hospital] Patient Rights and Responsibilities Poster must be placed in prominent locations within the hospital. 6. Patients’ Rights: Patients have the rights to: a) Considerate and respectful care given by competent personnel and to be made comfortable. b) Respect for cultural, psychosocial, spiritual, and personal values, beliefs, and preferences ... Have personal privacy respected. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. The patient has the right to be told the reason for the presence of any individual. The patient has the right to have visitors leave prior to an examination and when treatment issues are being discussed. Privacy curtains will be used in semi-private rooms ... Receive care in a safe setting ... The patient has the right to access protective services and advocacy services including notifying government agencies of neglect or abuse...” Review of the hospital’s QAPI meeting minutes from April 2024 through September 2024 the hospital had identified areas of non-compliance with medication carts not being locked and Patient’s Health Information (PHI) being left open and unattended on computers on wheels. During an observation of second floor north nurses’ station on 10/30/24 at 10:27 AM showed three unattended computers on wheels with patient information displayed on the screen. Further observation of the computers on wheels showed them unlocked and unattended with patient medications present in the drawers. During an observation of the second-floor south nurses’ station on 10/30/24 at 10:34 AM showed one unattended computer on wheels with patient information displayed on the screen. Further observation of the computer on wheels showed it unlocked and unattended with patient medications present in the drawers. During an observation of the first-floor nurses’ station on 10/30/24 at 10:45 AM, one unlocked and unattended computer on wheels with patient medications present in the drawers. Surveyors observed medication cart for approximately 5 minutes and the cart did not lock automatically nor did staff attempt to lock the cart. During an interview on 10/31/24 at 12:20 PM Staff J, RN stated that the computer on wheels have automatic locks and should lock after a few seconds. Staff J went on to state there is a computer on wheels that was broken. During an interview on 10/31/24 at 1:27 PM Staff B, Quality Manager stated, ...I go out and do physical audits and note unlocked medication carts, broken med carts, and unattended computers with PHI...Several staff were notified and retrained regarding unattended computers with PHI open. Broken computers on wheels should be put into locked med room until the computer on wheels is replaced ...”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 47233 Based on observation and interview, the hospital failed to protect patients’ health information by leaving medical record information readily available for anyone entering the hospital to see. Findings Include: Review of a hospital policy titled, “Patient Rights and Responsibilities” Revised 10/21/24 showed, “ ...1. Every patient admitted to a [The Hospital] hospital is given a written copy of the Patient’s Bill of Rights prior to admission, and, within 24 hours of admission, each patient is given an explanation of his/her rights and responsibilities as a patient. 2. The hospital will provide an explanation of the patient’s rights and responsibilities in the patient’s primary language, if requested. 3. The hospital shall obtain a signed copy of the Patient’s Bill of Rights from each patient or patient’s family, if appropriate. The signed copy shall include a statement that the patient and or patient’s family has read the document and understands the rights specified in the document. 4. The hospital shall retain a signed copy of the Patient’s Bill of Rights in the patients’ medical file. 5. The [The Hospital] Patient Rights and Responsibilities Poster must be placed in prominent locations within the hospital. 6. Patients’ Rights: Patients have the rights to: a) Considerate and respectful care given by competent personnel and to be made comfortable. b) Respect for cultural, psychosocial, spiritual, and personal values, beliefs, and preferences ... Have personal privacy respected. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. The patient has the right to be told the reason for the presence of any individual. The patient has the right to have visitors leave prior to an examination and when treatment issues are being discussed. Privacy curtains will be used in semi-private rooms ... Receive care in a safe setting ... The patient has the right to access protective services and advocacy services including notifying government agencies of neglect or abuse...” Review of the hospital’s QAPI meeting minutes from April 2024 through September 2024 the hospital had identified areas of non-compliance with medication carts not being locked and Patient’s Health Information (PHI) being left open and unattended on computers on wheels. During an observation of second floor north nurses’ station on 10/30/24 at 10:27 AM showed three unattended computers on wheels with patient information displayed on the screen. Further observation of the computers on wheels showed them unlocked and unattended with patient medications present in the drawers. During an observation of the second-floor south nurses’ station on 10/30/24 at 10:34 AM showed one unattended computer on wheels with patient information displayed on the screen. Further observation of the computer on wheels showed it unlocked and unattended with patient medications present in the drawers. During an observation of the first-floor nurses’ station on 10/30/24 at 10:45 AM, one unlocked and unattended computer on wheels with patient medications present in the drawers. Surveyors observed medication cart for approximately 5 minutes and the cart did not lock automatically nor did staff attempt to lock the cart. During an interview on 10/31/24 at 12:20 PM Staff J, RN stated that the computer on wheels have automatic locks and should lock after a few seconds. Staff J went on to state there is a computer on wheels that was broken. During an interview on 10/31/24 at 1:27 PM Staff B, Quality Manager stated, ...I go out and do physical audits and note unlocked medication carts, broken med carts, and unattended computers with PHI...Several staff were notified and retrained regarding unattended computers with PHI open. Broken computers on wheels should be put into locked med room until the computer on wheels is replaced ...”

“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: 47233 Based on policy review, record review, and interview the hospital failed to ensure nursing care was evaluated by a registered nurse (RN) on an ongoing basis to ensure that staff were providing the appropriate assessment, care, and evaluation of patient’s response to interventions for 5 (Patient 2, 3, 4, 5, and 6) of 6 patient records reviewed. These deficient practices placed the patient at risk for development of wounds, deterioration of current illness, and adverse outcomes. Findings Include: Review of a hospital policy titled, “Fall Prevention” Revised 03/20/24 showed, “ ...To provide a guide for assessing patients who are at risk for falling and for implementing precautionary measures to reduce the probability that a patient will fall or to reduce the probability the patient will sustain a serious injury in the event of a fall ... Risk assessment tools should be utilized as a frame of reference to enhance the predictability of patient falls and the selection of prevention strategies. Patients are assessed for the presence/absence of fall risk factors and given a score that identifies them as low, moderate, or high fall risk. Nurses will conduct an initial fall risk assessment. A fall assessment will then be conducted once a shift, and/or with any change in a patient’s clinical status and post-fall. Each hospital will identify low risk with a green indication outside the door, a yellow indication for moderate, and a red indication for high. The nursing fall risk assessment and interventions are based on the use of the modified Morse Fall Scale. Patients will be assessed for fall risk factors upon admission, daily, change in clinical status, transfer to a new setting, and post-fall ... POST FALL ASSESSMENT Initiate the Post Fall Algorithm Complete Post Fall Huddle Complete Fall Analysis Tool Enter the incident into the incident reporting system ... MANAGEMENT OF THE POST-FALL PATIENT ... Did patient strike head and/or on anticoagulants or platelet inhibitors? Yes/Unknown 1. Complete a thorough nursing assessment. Does the patient have any of the following: o Spinal pain or tenderness o Abnormal motor and sensory exam o Unconsciousness 2. Obtain vital signs and neuro checks, which are to occur: o Every 15 minutes, times 4 o Every 30 minutes, times 2 oEvery hour, times 4 3. Initiate High Fall Risk Interventions, as applicable for a patient. 4. Notify nursing supervisor ...” Patient 2 Review of Patient 2’s medical record showed a 73-year-old male that was admitted to the hospital on 06/21/24 at 5:29 PM with an admitting diagnosis of Encounter for other orthopedic aftercare. Past medical history includes history of hypertension (elevated blood pressure); Atrial fibrillation (AFib) (irregular and often very rapid heart rhythm); and obesity. Patient 4 discharged to a Skilled Nursing Facility on 07/12/24 at 2:50 PM. Review of a document titled, “Physician’s Order” showed “Original Order Start ...06/21/2024 ... Vital Signs Every 12 Hours Vitals, Request Type: Routine ...DC [Discontinue] Date 07/12/24 ...” Review of a document titled, “Vital Signs” showed from 06/21/24 at 6:00 PM through 07/12/24 at 6:11 AM nursing staff failed to obtain Patient 2’s vitals as ordered by the physician 12 of 40 times. Patient 3 Review of Patient 3’s medical record showed a 54-year-old female that was admitted to the hospital on 09/28/24 at 4:39 PM with an admitting diagnosis of Paraplegia (impairment in motor or sensory function of the lower extremities). Past medical history includes history of Acute Respiratory Failure with Hypoxia (lungs have a hard time loading your blood with oxygen or removing carbon dioxide), Adrenal Insufficiency (occurs when the adrenal glands don’t produce enough hormones), Asthma- chronic obstructive pulmonary disease (COPD), overlap syndrome (mix of symptoms of both asthma and chronic obstructive pulmonary disease) Chronic Pain, Obesity, and Hypertension (elevated blood pressure). Patient 3 discharged to a skilled nursing facility on 10/18/24. Review of Patient 3’s medical record failed to show a physicians order for vital signs per policy from 09/28/24 at 4:49 PM through 10/18/24 at 3:57 PM. Review of a document titled, “Vital Signs” showed from 09/28/24 at 4:49 PM through 10/18/24 at 3:57 PM nursing staff failed to obtain Patient 3’s vitals 10 of 38 times. Patient 4 Review of Patient 4’s medical record showed a 79-year-old female that was admitted to the hospital on 09/11/24 at 9:15 PM with an admitting diagnosis of Unspecified symptoms and signs involving cognitive functions following cerebral infarction. Past medical history includes history of recurrent Cerebrovascular accident (CVA) with residual weakness and memory deficit and dementia. Patient 1 discharged home on 09/27/24. Review of a document titled, “Nursing Admission Assessment” dated 09/11/24 at 9:15 PM showed, “ ...Morse Fall Risk Assessment ... History of Falling (immediate or within 3 months) Yes (25) Secondary Diagnosis/More Than One Diagnosis Yes (15) Ambulatory Aid Crutches/cane/walker/wheelchair (15) Continuous IV Infusion or Heplock No (0) Gait Weak (10) Mental Status Overestimates or forgets limits (15) Morse Falls Screening Total Score Greater than 45: High Fall Risk Minimal Fall Prevention Interventions Maintained for ALL Patients: Fall Assessment completed, bed wheels locked, bed in low position, call light within reach, environment assessed for all risks, personal items within reach, Plan of Care updated as needed Morse Fall Risk Assessment Total Score: 80.00 ...” Review of a document titled, “Nursing Shift Assessment” dated 09/12/2024 at 5:56 PM showed, “ ...Morse Fall Risk Assessment History of Falling (immediate or within 3 months) No (0) Secondary Diagnosis/More Than One Diagnosis Yes (15) Ambulatory Aid Crutches/cane/walker/wheelchair (15) Continuous IV Infusion or Heplock No (0) Gait Weak (10) Mental Status Knows own limits (0) Morse Falls Screening Total Score 25-45: Moderate Fall Risk Minimal Fall Prevention Interventions Maintained for ALL Patients: Fall Assessment completed, bed wheels locked, bed in low position, call light within reach, environment assessed for all risks, personal items within reach, Plan of Care updated as needed Morse Fall Risk Assessment Total Score: 40.00 ...” Review of Patient 4’s medical record failed to show an appropriate Morse Fall Risk score was completed on Patient 4 on 09/12/2024 at 5:56 PM. Review of a document titled, “Notes” showed, “ ...while receiving report this 0650 [6:50 AM], pt [patient] reported had a fall in BR [bathroom] last night, and C/O [complaint of] pain on head, back and finger. Electronically Signed By: [Staff C] RN, 09/13/2024 14:47 [2:47 PM] ...” Review of a document titled, “Nursing Serial Neuro Assessment” dated 09/13/24 at 9:15 AM showed, “ ...Reason for Neurological Assessment: Post-Fall Assessment ...Glasgow Coma Scale Total Score: 15.00 ...” Initiated two hours post patient fall. Review of Patient 4’s medical record failed to show the post fall assessment was completed per policy by failing to initiate neurological checks immediately following Patient 4’s fall. Review of a document titled, “Patient Incident Report” showed, “ ...Incident Date: 9/13/2024 Incident Time: 02:32 PM ... Follow Up/Resolution: There is no report of bed alarm sounding at the time of the patient getting out of fall, no physical evidence of all on the patient’s person. Patient had dementia and is forgetful...The patient report was treated as an unwitnessed fall ...Morse Fall risk assessment was completed in shift assessment, Neuro checks were completed by day nurse ...with the frequency: q 15 [every 15] min [minutes] x 4 [times 4], q 30 [every 30] min x2 [minutes times 2], Q [every] 1 hr [hour] x4 [times 4 hours]. However, the first neuro check was completed at 0915 [9:15 AM] about two hours after the patient reported the fall to the nurse ...” During an interview on 10/29/24 at 1:28 PM Staff C, RN stated that the process when a patient has an unwitnessed fall is to immediately report to charge nurse, start vitals, neuro checks, notify physician, if complaint of hitting head request x-ray and computed tomography (CT). When a patient is a high fall risk implement yellow wrist bands, fall risk signs on door, bed alarm, chair alarms, and non-slip socks. Review of a document titled, “Physician’s Order” showed “Original Order Start ...09/12/24 ... Vital Signs Every 12 Hours Vitals, Request Type: Routine ...DC [Discontinue] Date 09/27/24 ...” Review of a document titled, “Vital Signs” showed from 09/11/24 at 10:PM through 09/27/24 at 10:17 AM nursing staff failed to obtain Patient 4’s vitals as ordered by the physician 3 of 26 times. During an interview on 10/29/24 at 1:28 PM Staff C, RN stated that vital signs are to be done every shift. Patient 5 Review of Patient 5’s medical record showed a 69-year-old female that was admitted to the hospital on 09/04/24 at 3:30 PM with an admitting diagnosis of Ataxia following cerebral infarction. Patient 5’s medical record showed patient was dependent on all cares and a high fall risk during entire hospital stay. Patient 5 remained inpatient until her time of discharge on 09/18/24 at unknown time. Review of a document titled, “Patient Incident Report” showed, ...Incident Date:09/06/24 Incident Time: 12:51 AM ... Follow Up/Resolution: This was in the early morning hours, Usually not a very busy time of the shift. Reminded staff to respond to fall alarms in a timely manner. Review of post fall documentation showed that (a) Morse Fall Risk Assessment was not completed post fall -education given to Staff L, nurse for the patient at the time of the fall (b) The patient is on Plavix, a blood thinner and needed neuro checks completed post fall per fall algorithm stated in Fall policy. Neuro checks were completed with the frequency Q 21 min x 1, q 15 min x 2, q 30 min x2, q 1 hour x 4.” Review of Patient 5’s medical record failed to show the post fall assessment was completed per policy by failing to initiate neurological checks immediately following Patient 5’s fall. Review of document titled, “Order Listing Report For 09/04/24 to 10/28/24” showed, “All Order Status For Patient 5 ...Vital Signs Every 12 Hours Vitals Start Date & Time 9/04/23 19:30 End Date & Time 9/18/24 10:18* Ordering Clinician ...” Review of Patient 5’s medical record failed to show any blood pressure readings completed per policy by failing to initiate vital signs every 12 hours on 09/04/24- 09/07/24, 09/09- 09/13/24, 09/15/24 and 09/17/24. Review of Patient 5’s medical record failed to show any blood pressure readings completed for 24 hours per policy by failing to initiate a nursing assessment with vitals every shift on 09/08/24 and 09/14/24. Patient 6 Review of Patient 6’s medical record showed an 82-year-old female that was admitted to the hospital on 10/09/24 at 5:40 PM with an admitting diagnosis of other specified myopathies, multiple recurrent wounds. Patient 6’s medical record showed patient was dependent on most cares during entire hospital stay. Patient 6 remained inpatient until her time of discharge on 10/25/24 at an unknown time. Review of document titled, “Order Listing Report For 10/09/24 to 10/28/24” showed, “All Order Status For Patient 6 ...Vital Signs Every 12 Hours Vitals Start Date & Time 10/09/24 19:30 End Date & Time 10/25/24 14:06* Ordering Clinician ...” Review of Patient 6’s medical record failed to show blood pressure readings completed per policy by failing to initiate vital signs every 12 hours on 10/10/24, 10/13/24, 10/21/24, and 10/23/24.”