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Based on document review, observation, policy review and staff interview, the facility failed to follow a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs for three high risk fall patients of three rooms observed of patients at high risk for falls (Patients #3, #13 and #14). The total sample was 10 patients. The facility's census at the time of the survey was 405.

Findings include:

Review of the facility's Fall Minimization and Post Fall Care, Adult Protocol (Version 4, Effective Date 09/25/19) revealed: Place high fall risk symbol on doorframe/curtain outside patient's room or utilize call light system to indicate high fall risk if available.

Per the facility's census on 06/28/23 at 7:48 AM, Patient #3, #13 and #14 were at high risk for falls. The outside of the rooms for Patient #3, #13 and #14 were observed on 06/28/23 at 8:52 AM. The high fall risk light was not illuminated to indicate high risk for fall.

The findings were shared with Staff B and confirmed in an interview on 06/28/23 at 8:52 AM.

This deficiency represents non-compliance investigated under Substantial Allegation OH00143966.