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Falsifying Charting Sentinel Event

Shaylee Hawn

California State University, Stanislaus

NURS 3320: Leadership and Management

Dr. Marla Seacrist

November 8, 2022
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Falsifying Charting Sentinel Event

In the year of 2021 alone, there were 710 sentinel events related to patient falls (The Joint

Commission, 2022). Sentinel events are accidents or near-misses that harm the patient in any

way or cause death (The Joint Commission, 2022). One specific sentinel event happened when a

patient at a nursing home died as a result of complications from an unwitnessed fall. A root cause

analysis of the event revealed that the facility was understaffed and failed to implement several

safety precautions, such as including a fall prevention plan, reporting known falls, and frequently

monitoring patients who have a high risk of falling. A quality improvement plan was developed

to help prevent falls from happening in the future which includes scanning patient barcodes,

mandating nurse-to-patient ratios, and implementing centralized video observation. An

evaluation of the plan, using Kirkpatrick’s Evaluation Model, will maintain that the steps taken

are producing the expected results, a reduced number of patient falls.

Sentinel Events

The Joint Commission describes sentinel events as patient safety events that cause the

patient temporary or permanent injury and in severe cases, death (The Joint Commission, 2022).

The Joint Commission is a not-for-profit agency that advocates for patient safety and aims to

ensure quality healthcare by evaluating and accrediting healthcare organizations and providing

feedback to improve patient care (Wadhwa & Huynh, 2022). Therefore, when a patient suffers

temporary or permanent damage or dies in a medical facility, an investigation into the event can

help understand why it happened as well as prevent it from ever happening again. Sentinel events

frequently reviewed by The Joint Commission include falls, unintended retention of a foreign

object, wrong surgery, suicide, and delay in treatment. The number of reported sentinel events in

2021 ranked an all-time high of 1,197 events. Sentinel events indicate that there is a lack of
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safety protocols and procedures to prevent that event from happening, therefore, immediate

research and response is required to prevent the same event from happening again (The Joint

Commission, 2022).

When a sentinel event occurs, the organization is strongly encouraged, but most are not

required to report the event to The Joint Commission (The Joint Commission, 2022). According

to the Agency for Healthcare Research and Quality (AHRQ), only 11 states have mandated that

medical facilities report sentinel events while 16 states mandate reporting of serious adverse

events (AHRQ, 2019). When The Joint Commission is notified of a sentinel event, the

organization is expected to complete a comprehensive systematic analysis and corrective action

plan within 45 business days of the event (The Joint Commission, 2022). This analysis and

action plan should be submitted to The Joint Commission, who will review and evaluate the

material. When The Joint Commission determines that the analysis and action plan are

acceptable and will effectively reduce the risk of further events, a follow up activity will be

assigned to the organization to promote safety and prevent the possibility of reoccurrence. The

Joint Commission evaluates the organization’s response to the event using data collected through

the sentinel event measure of success process. This process evaluates the effectiveness of the

planned corrective actions so that the organization may get approval or additional feedback and

solutions if needed (The Joint Commission, 2022).

Sentinel Event Case

In April 2018, an 84-year-old man, Mr. King endured a stroke and was admitted to

Cathedral Village, a nursing care facility in Philadelphia, for rehabilitation on April 9, 2018

(Jean, 2022). Mr. King stayed at the rehabilitation facility for three days until he was transferred

to Cathedral Village’s senior living facility on April 12th. At approximately 11:30 p.m. on the
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same day, a staff member found Mr. King on the floor in his room after an unwitnessed fall. Mr.

King was assisted back into his bed before the nurse left him to sleep for the night. When a nurse

went to check on Mr. King the next morning on April 13, 2018, at 7:00 a.m., King was

discovered deceased in his wheelchair in the lobby of the facility. Mr. King’s autopsy revealed

that he had sustained a subdural hematoma as a result of his fall. After Mr. King’s stroke and

then an unwitnessed fall, he required routine neurological checks to assess for any deficits in his

neurological status. Summer, the Licensed Practical Nurse (LPN) responsible for this patient,

documented that she completed eight neurological checks on this patient after his fall. However,

upon further investigation, video footage at the care facility revealed that she had not checked on

or performed any neurological assessments on Mr. King between the time of his fall and the time

he died. If Nurse Summer had completed these neurological checks, she could have identified

Mr. King’s deteriorating status so that he could be transferred to a hospital for more acute care

and possibly saved his life. It is important to note that Mr. King’s fatal fall was not his first, in

fact, it was his fifth during his four days at Cathedral Village. Additionally, while Nurse Summer

was responsible for caring for Mr. King at the time of his death, she was also responsible for

caring for 36 other patients at the same time (Jean, April 21, 2022).

Root Cause Analysis

A fishbone diagram analyzes and portrays all the factors that ultimately made this

sentinel event possible (see Appendix A). Environment, equipment, leadership, communication,

people, and procedures are all components of the fishbone. Another useful tool is the strengths,

weaknesses, opportunities, and threats (SWOT) analysis (see Appendix B). A SWOT chart can

help analyze what went well during the event as well as what needs to be improved. Both tools
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were created to get a better picture of this specific event and to find ways to prevent it from

reoccurring.

For the first category of the fishbone regarding environment, Mr. King’s fall happened at

a facility that was severely understaffed with unsafe patient ratios averaged between 30-60

patients per nurse. Nurse Summer had 37 patients to care for during her shift, including patients

with dementia, behavioral issues, psychiatric illnesses, and therapy patients like Mr. King. This

was a common ratio for nurses at Cathedral Village at the time even though staff was aware that

this was an overwhelming and dangerous workload, which makes this a problem in the

leadership category. Leadership positions at Cathedral Village also failed to provide adequate

supervision and interventions to prevent falls for patients with a fall risk. Under the equipment

category, the absence of a cameras in patient rooms and a central monitor at the nurse’s desk

required nurses to walk to each patient’s room to simply check the patient’s vitals. This is why

Mr. King was not discovered until the next morning. For the category regarding communication,

poor staff communication meant that the frequency of Mr. King’s falls was not made apparent to

the senior living facility when he was transferred from the rehabilitation facility on the same

premises. When Mr. King was found on the floor after his last fall, it was not reported to his

primary nurse or supervisors on that shift. For the category regarding people, Nurse Summer

could have also underestimated the severity of Mr. King’s status or lack the knowledge to know

how important neurological checks are, especially for a stroke patient who had an unwitnessed

fall. Mr. King’s deteriorating neurological status could have been identified earlier had the nurse

simply walked into his room to check on him or asked someone else to. For the category

regarding procedure, based on Mr. King’s neurological status, he should have been placed in a
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1:1 ratio instead of 37:1. Additionally, a fall prevention plan was not put in place or carried out

to prevent Mr. King’s fatal fall (see Appendix A).

For the strengths category of the SWOT analyses, a thorough investigation was

completed on this incident to determine the contributing factors. Additionally, the Nurse Summer

knew that she was supposed to chart the neurological assessments because she falsely

documented them. Weaknesses of this event include the facility being severely short staffed with

unsafe ratios, Mr. King was not on a fall prevention plan, and neurological assessments were not

performed. Mr. King was also not routinely assessed, and his fatal fall was not reported to the

primary nurse and supervisors. The nurse was forced to falsify charting due to a lack of time and

had no legal protection. Opportunities include increasing nurses’ knowledge regarding

neurological checks, encouraging communication between nurses and leadership, and providing

quick methods to monitor a patient’s status. Additionally, other opportunities include adding all

risks to care plans, developing a fall reporting system, increasing communication between all

facilities, and requiring patient scans before neurological checks. Threats include continued short

staffing, lack of safety protocols, and shortcuts of preventative measures (see Appendix B).

Quality Improvement Plan

Understaffing with unsafe ratios, lack of time to frequently monitor patients, and failed

assessments ultimately led to the death of Mr. King. To prevent this type of event from

happening again, video observation systems should be put in place for fall risk patients, safe

nurse-patient ratios should be mandated by law in every state, and time-sensitive, high-acuity

assessments should require patient barcode scanning. To implement this quality improvement

plan in a timeframe of 7 years, leadership positions, nurses, physicians, social workers, local

politicians, patients, and local and state governments must be involved. Nurses, physicians, and
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social workers need to be involved because this plan will affect their workflow and how they

assess and care for patients. Leadership positions such as Chief Executive Officers of nursing

homes and hospitals will need to authorize and initiate this plan as well as accommodate for the

new requirements. Local politicians, as well as local and state governments need to be involved

to draft laws and help push through the legislation required to implement safe staffing. The goal

of the quality improvement plan is to decrease patient deaths related to and the total number of

falls in hospitals and nursing homes.

Ratio Laws

The most important intervention to prevent this event from reoccurring is nurse-patient

ratio laws in each state. Currently, California is the only state that legally requires set nurse-to-

patient ratios in each hospital unit (Davidson, 2022). Nine other states, including Connecticut,

Nevada, Ohio, Texas, Minnesota, Illinois, New York, Oregon, and Washington have hospital-

based staffing committees that review the hospitals needs and the number of nurses to determine

nurse-to-patient ratios (Davidson, 2022). Five of these states require hospitals to report hospital

staffing to the state (Davidson, 2022). This means that nurses are often left with unsafe ratios

when there are large volumes of patients because the hospital has no legally required nurse-to-

patient ratios. A positive response is expected from patients, nurses, physicians, and other

hospital staff as ratio laws create a safer environment for patients and allow for more thorough

care. While there may be pushback from lawmakers and the CEO’s and governing boards of

medical facilities due to the amount of time to pass ratio laws and the financial requirements of

staffing more nurses, this change is necessary to ensure patient safety and prevent future sentinel

events. A research study performed in 11 different hospitals demonstrated that the number of

staffed nurses can accurately predict patient falls: increased staffing results in fewer patient falls
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(Kalisch et al., 2012). Additionally, fall rates decrease when routine nursing care is completed

(Kalisch et al., 2012). Therefore, mandating adequate staffing can prevent falls from happening

and can provide nurses with enough time to complete required care on each of their patients

which also reduces fall rates.

Patient Barcode Scanning

Barcode medication administration (BCMA) on the electronic medical record (EMR) has

been proven to reduce medication administration errors by 80% (Bonkowski et al., 2013).

Therefore, barcode scanning can be used to prevent errors in neurological checks, like wrong

time, wrong patient, or failure to complete. Requiring nurses to scan the patients barcode in order

to electronically document and confirm that the neurological assessment was performed correctly

verifies that the nurse assessed the patient due to the importance of these assessments. Most

hospital staff and patients will welcome this component of the quality improvement plan while

nurse may push back due to the additional measure added on their task load. However, scanning

the patient’s barcode is an extremely quick process that should only add seconds to the time it

takes to complete a neurological assessment. Additionally, this can verify that the assessment

was done at the correct time due to the time-sensitivity of these assessments. This adaption into

EMR’s can easily be introduced into hospitals as well as nursing homes to decrease the overall

rate of missed or delayed neurological assessments.

Centralized Video Observation

As about 63% of injury-related falls in older adults result in death, preventing falls is of

imminent importance (James & Carter-Templeton, 2021). This is especially true in rehabilitation

centers and nursing homes, where many patients experience altered mental statuses, are

recovering from recent injury or trauma, and are sometimes on multiple medications that affect
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gait. Additionally, 73% of stroke patients, like Mr. King, fall within the first year after a stroke.

When analyzing the benefits of installing centralized video observation in rooms of 34 high fall-

risk patients, fall rate decreased by 100% over the 6-week period. Incorporating centralized

video observation (CVO) into fall prevention plans is a way to monitor patients at all times as

well as providing an effective alternative to patient sitters. A bonus benefit of video observation

is decreased money spent on sitters as well as potential falls, with the estimated saving of this

specific study being $88000 (James & Carter-Templeton, 2021). Positive feedback is expected

from nurses and other hospital staff including leadership positions because this is an easy and

quick way to assess patients and increases patient safety while minimizing unfortunate events.

However, mixed feedback is expected from patients and their families as some people feel that

cameras are an invasion of privacy. These feelings can be addressed by educating the patient and

their family on increased safety created with cameras and refraining from using cameras in

patient rooms who strongly object to it. CVO can be installed in the rooms of each patient who is

suspected to or has a history of high risk for falls as way to quickly assess a patient’s status

rather than relying on nurses to constantly check on a patient or hiring sitters for every patient

with a fall risk. This requires cameras to be installed in patient rooms as well as a central desk

with monitors where a monitor technician can watch video surveillance from multiple rooms at

the same time.

Change Strategy

Dr. Kotter’s change model is a successful strategy to implement this quality improvement

plan. The first step is to create a sense of urgency (Kotter, n.d.). A sense of urgency can be

created by educating the public about the statistics and severity of falls in hospitals and

outpatient settings. As the numbers of falls continues to dominate the list of the most common
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sentinel events, this issue is not one that should be left undiscussed (The Joint Commission,

2022). Politicians and local and state governments need to be informed of the unsafe nurse-to-

patient ratios until change is enacted in each of the 49 states that does not have a ratio law. The

second step is to create a volunteer network of individuals committed to solving the problem at

hand (Kotter, n.d.). This can be by educating and encouraging nursing staff, physicians, hospital

boards, politicians, and local and state governments about their role in advocating for and

maintaining patient safety. The third step is to form a strategic vision to demonstrate how the

future will be improved with the implementation of this plan (Kotter, n.d.). By informing nursing

standards organizations, hospital CEO’s, medical staff, and government officials how adopting

patient barcode scanning for neurological assessments, implementing safe staffing ratios, and

incorporating CVO into medical facilities can save patient lives, the created plan of action can be

put into motion in every hospital and outpatient setting. The fourth step is to enlist a volunteer

army because wide-scale change happens only when large numbers of people are working

together to solve the issue (Kotter, n.d.). Creating a large group of dedicated people can be

accomplished by having sign up campaigns at medical facilities across the country as well as

recruiting the public through social media campaigns. This will recruit a wide variety of

volunteers who will advocate for safe staffing and fall prevention plan updates in their state as

well as encouraging additional peers to become part of the campaign. The fifth step is to enable

action by removing any barriers to progress (Kotter, n.d.).

Barriers can include negative feelings or resistance towards the quality improvement plan

and medical facilities’ unwillingness to incorporate these changes. The best way to remove these

barriers is continued education about the increased patient safety that the plan will bring forth

and legally enforcing ratio laws. Additionally, advocating for nursing ratios can encourage more
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students to go into the nursing profession or more ex-nurses to return to nursing, which could

help decrease staffing problems that hospitals currently face. The sixth step is to generate short

term wins (Kotter, n.d.). This can include tracking progress of the number of volunteers

advocating for this quality improvement plan as well as recognizing facilities who are quick to

implement CVO and patient barcode scanning for neurological assessments. The seventh and

eighth steps are to continue accelerating in the plan and to institute change by evaluating systems

to reinforce the new behaviors (Kotter, n.d.). This can be done by keeping track of falls and

patient outcomes at facilities that have implemented all of these changes and evaluating whether

the improvement plan has been beneficial or not and revising as needed.

Implementation

This plan will be implemented over a span of 7 years with 2030 being the cutoff date for

the three interventions to be in place at every medical facility in the country. The first steps

include educating and encouraging nursing staff, physicians, hospital boards, politicians, and

local and state governments about their role in advocating for and maintaining patient safety.

Education and advocacy will take place over the first two years to build large fall prevention

advocacy groups to meet with and influence hospital boards, national nursing organizations, and

government officials to get everyone on the same page. Educational meetings will be offered at

every major hospital in each state with the requirement that charge nurses and supervising

hospital and nursing home staff have to attend one meeting so that they can bring the information

back to their peers. Patient barcode scanning for neurological assessments and CVO are

interventions that can be nationally implemented into fall prevention plans within 3 years.

Legally enforcing ratio laws and implementing change in the national standard for fall

prevention is a lengthy process that will be in the process of acceptance during years 3-7 and
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finalized by 2030. While pushback is to be expected along the way, this quality improvement

plan was developed solely for the purpose of patient safety and had been given a generous

timeframe of 7 years as the lawmaking process is known to be complicated and lengthy.

Kirkpatrick’s Evaluation Model will be used to determine whether or not the quality

improvement plan produced the expected results of decreased patient deaths related to falls.

Level 1 determines the participants response toward the plan (Kirkpatrick Partners, 2022). This

will consist of a 5-star rating system used by nursing and medical staff after the 2 years of

education to understand how they feel about the plan affecting their workflow. The responses

will be analyzed to determine if there is any additional education or tools that should be provided

in order to ease the implementation of the quality improvement plan. Level 2 consists of

evaluating if the participants retained information presented in the educational meetings

(Kirkpatrick Partners, 2022). A 10-question retention quiz about fall prevention will be required

for each person responsible for patient care, specifically nurses, to take after being presented

with the information with a passing score of 80% required. This will also be administered after

the 2 years of education. Level 3 determines if the information had been applied in practice

(Kirkpatrick Partners, 2022). This will be done by facilities continuing to monitor and report

staffing ratios as well as the number of patient falls and barcode scanning rates for neurological

assessments. Level 4 analyzes the benefits implementing the plan has provided (Kirkpatrick

Partners, 2022). The number of patient falls reported to The Joint Commission will be analyzed

and compared to past numbers which will be published online for each medical facility to

review. Hospital specific results will be sent to each facility so that they can determine if they are

personally improving. National monitoring of barcode scanning rates for neurological

assessments will be conducted in 2032 by analyzing the scanning rates at each facility and
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addressing any concerns. Staffing levels of each medical facility will also be analyzed in 2032 to

confirm that ratio laws are being followed. Staffing ratios, patient deaths related to falls, and fall

rates will be required to be reported to The Joint Commission so that results can be published

online and sent to every medical facility.

Creating a safe patient outcome is one of the biggest priorities for healthcare personnel.

Mr. King is one of the many patients who have died after sustaining an unwitnessed fall in a

medical facility that was severely understaffed. With the root cause analysis showing multiple

safeguards being neglected, including implementing a fall prevention plan for a patient with a

history of falls, performing neurological assessments after a fall, and reporting and documenting

falls, a quality improvement plan consisting of enforced ratio laws, barcode scanning for

neurological assessments, and centralized video observation has the possibility of decreasing the

number of patients falls significantly, if not completely. Additionally, the evaluation process

using Kirkpatrick’s Evaluation Model will provide important feedback that can be used to

improve the quality improvement plan to make it even more efficient. Implementing this quality

improvement plan has the ability to prevent patient deaths related to falls and prevent patient

falls altogether.
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References

Agency for Healthcare Research and Quality. (2019). Never events.

https://psnet.ahrq.gov/primer/never-events#:~:text=Sentinel%20events%20are

%20defined%20as,analysis%20after%20a%20sentinel%20event.

Bonkowski, J., Carnes, C., Melucci, J., Mirtallo, J., Prier, B., Reichert, E., Moffatt-Bruce, S., &

Weber, R. (2013). Effect of barcode-assisted medication administration on emergency

department medication errors. Academic Emergency Medicine, 20(8), 801-806.

https://doi.org/10.1111/acem.12189

Davidson, A. (2022). Nurse-to-patient staffing ratio laws and regulations by state. Nurse

Journal.

https://nursejournal.org/articles/nurse-to-patient-staffing-ratio-laws-by-state/

Davis, J. E. & Carter-Templeton, H. (2021). Augmenting an inpatient fall program with video

observation. Journal of Nursing Care Quality, 36(1), 62-66.

https://doi.org/10.1097/NCQ.0000000000000486

Jean, J. Y. (April 21, 2022). How short-staffing and unsafe patient ratios led to the

sentencing of former nurse Christann Gainey. Nurse Journal.

https://nursejournal.org/articles/short-staffing-unsafe-patient-ratios-mcmaster-christiann-

gainey/#:~:text=It%20is%20reported%20Gainey%20was,the%20morning%20of%20his

%20passing

Kalisch, B. J., Tschannen, D., & Lee, K.H. (2012). Missed nursing care, staffing, and patient

falls. Journal of Nursing Care Quality, 27(1), 6-12.

https://doi.org/10.1097/NCQ.0b013e318225aa23.
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Kirkpatrick Partners. (2022). The Kirkpatrick Model. https://www.kirkpatrickpartners.com/the-

kirkpatrick-model/

Kotter. (n.d.). The 8 steps for leading change. https://www.kotterinc.com/methodology/8-steps/

The Joint Commission. (2022). Sentinel event.

https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/

Wadhwa, R. & Huynh, A. P. (2022). The Joint Commission. National Center for Biotechnology

Information. https://www.ncbi.nlm.nih.gov/books/NBK557846/
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Appendix A

Environment Equipment Leadership

Understaffed facility No cameras in Unsupportive leadership

patient rooms
Lack of patient assessments Poor staff communication
for change in condition
No central monitor with all
patient’s vitals/alarms
Many time demanding patients: No supervision or
dementia, behavioral issues, etc. interventions to prevent falls Patient
falls,
results in
No discussion of fall Lack of time to provide death
prevention for this patient required care

Oversight of fall risk and

Failure to relay significance Lack of knowledge, deteriorating condition
of pt’s fall history poor prioritization

Failure to report fall Lack of patient monitoring No fall prevention plan

Communication People Procedure

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Appendix B

Strengths Weaknesses Opportunities Threats

-thorough -short staffed -increasing nurses’ -continued short
investigation was -unsafe patient ratios knowledge r/t staffing and unsafe
completed on this -patient was not on a neurological checks ratios
incident fall prevention plan -encouraging -lack of safety
-nurse Summer knew -neurological checks communication protocols
she was supposed to were not completed between leadership -short cuts of
chart neurological -patient was not and nurses preventative
assessments routinely routinely assessed -providing quick measures and
-fall was not reported ways to monitor continued false
to primary nurse and patient’s status charting due to short
supervisors -making sure staffing
-no protection for patient’s plan of care
nurses from legal includes all known
action risks
-falsifying charting -develop fall
reporting system that
notifies all staff
-increase
communication
among facilities
patients are
transferred between
-require patient
scanning before
important
assessments such as
neurological checks
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5 Introduction
interesting first sentence, no use of "this author" or "in this
paper" Then include the major points from sentinel events in
general, from your specific event, the root cause, the QI plan,
the evaluation and dissemination.
10 Sentinel Events in General

10 Sentinel Event Case

20 Root Cause Analysis Narrative

Fishbone diagram either in text or as appendix
SWOT table either in text or as appendix
Narrative description of findings
40 Quality Improvement Plan
clear problem statement
objective or aim of the quality improvement plan
stakeholders (who and why)
attitudes, beliefs, and knowledge of stakeholders
describe ideal change, including resources (3 elements)
describe the research to support each element
discuss change strategy (theory)
detail implementation of change including timeline
evaluation plan
how results will be shared
5 Conclusion
includes an overview of the whole paper in general, including
the major points from sentinel events in general, from your
specific event, the root cause, the QI plan, the evaluation and
dissemination. Should end with a motivational sentence for
quality patient care.
10 APA