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Based on document reviews and interviews, the facility failed to ensure patients who experienced a fall event received follow-up nursing care. The failure was identified in 2 of 2 medical records, (Patients #1 and #5) for patients who experienced a fall event. Specifically, the facility failed to ensure staff provided follow-up care and monitored the patient's condition for subsequent injuries.

Findings include:

Facility policy:

According to the Fall Risk Prevention policy, the following nursing care procedures are required upon the discovery of a patient who has experienced a fall. When a patient falls, the facility staff engages the overhead paging system to announce a "Code Yellow". This process alerts staff and supervisory staff of the patient room number where the patient fall occurred. This call initiates a response team including the Nursing House Supervisor, the Nursing Unit Manager, the Nursing Unit Director, the Charge Nurse, any Physical Therapy and Occupational Therapy staff available, the Registered Nurse and the Certified Nursing Assistant providing care for the patient.

Upon finding a patient who has experienced a fall, an assessment of the patient is conducted including vitals signs. After the assessment, the patient is transferred to the bed or chair as indicated. The response team conducts a fall debrief using the "Code Yellow Form." This debrief process includes the patient and family as appropriate. A "Code Yellow Debrief" form is sent to the nursing unit manager or nursing unit director.

The patient is reassessed for a fall risk. The post fall assessment is documented in the patient's electronic health record. The facility staff notifies the patient's physician. With the patient's permission, the facility staff notify the patient's family members unless the patient is non-decisional. The facility will notify the Medical Durable Power of Attorney (MDPOA) as indicated. The facility staff will then complete the Risk Management Notification in the patient's electronic health record.

1. The facility failed to ensure nursing staff assessed, evaluated, and managed patient injuries after patients experienced a fall according to facility policies.

a. Review of documentation dated 9/15/20 at 5:16 a.m. revealed Patient #5 experienced a witnessed assisted fall when the patient rolled sideways out of bed and hit his back. The report revealed the patient injured his back and a small abrasion was noted. Two nurses assisted Patient #5 back to his bed.

i. Patient #5's medical record was reviewed. Patient #5's medical record lacked a nursing assessment, location of the abrasion, or documentation of follow-up care for the injury to the patient's back and abrasion following his witnessed fall on 9/15/20.

ii. On 11/4/20 at 1:12 p.m., an interview was conducted with Nurse Manager #5 (NM #5). NM #5 reviewed Patient #5' s medical record. NM #5 was unable to locate documentation regarding the location and characteristics of the patient's injury after the patient fell. NM#5 acknowledged nursing assessment and follow-up care for Patient #5's injuries were not conducted.

b. Review of a report dated 8/10/2020 revealed, Patient #1 fell two days earlier on 08/08/2020. The staff member who entered the report documented she assessed Patient #1 and the patient had a bruise on her buttocks.

i. Review of Patient #1's medical record revealed the patient had a change in mental status following a back surgery. Patient #1 became impulsive and frequently got out of bed without staff assistance, and she was noted to be high risk for falls.

ii. Review of a nursing note entered on 8/10/20 revealed Patient #1 and the patient's family member informed the nurse Patient #1 fell and was injured on 8/8/20. The nurse subsequently assessed Patient #1 and found the patient had a bruise on her inner buttocks. The nurse documented there were no previous notes regarding Patient #1's fall and bruise.

iii. Review of Patient #1's medical record revealed nursing staff who cared for Patient #1 on 8/8/20 did not document the patient's fall or bruise. There was no evidence in the medical record of nursing assessment of the bruise or follow-up evaluation and interventions between 8/8/20 when the fall occurred and 8/10/20 when the patient and family member reported the fall to the nurse. Additionally, the medical record did not show evidence of coordination with the patient's physician or family after the patient fell.

iv. On 11/03/2020 at 4:00 p.m., an interview was conducted with Registered Nurse (RN) #2, who cared for Patient #1 on 8/8/20. RN #2 stated Patient #1 fell out of bed onto the protective floor mat. She stated the charge nurse told her since the patient fell on the protective floor mat it was not necessary to activate the "Code Yellow" alert system. RN #2 stated the patient did get a bruise on her buttocks. RN #2 stated she did not write a patient assessment in the medical record because she did not think a patient falling on a floor mat was considered a fall. She stated she did not document a skin assessment for the same reason.

This was in contrast to the facility Fall Risk Prevention policy, which read if a patient fell, staff were to announce a Code Yellow, conduct an assessment of the patient's condition, reassess the patient's fall risk, complete a post-fall debrief, and complete a Risk Management notification.

2. The facility failed to consistently provide nursing care for patients who experienced a fall. The facility failed to ensure follow-up nursing assessment, care and evaluation for patients subsequent to fall injuries according to facility policy.

a. An interview with nursing leadership revealed nursing staff were required to complete specific actions in response to a patient fall.

i. On 11/4/20 at 1:12 p.m., an interview was conducted with Nurse Manager #5 (NM #5). NM #5 stated a fall was defined as any patient found on the ground. NM #5 stated this definition included falls which were witnessed or unwitnessed, and also included falls on the protective mat or on the bare floor. According to NM #5, when a patient fell the nurse completed an assessment of the patient's condition and documented any injuries or abrasions in the electronic medical record. NM #5 stated when a patient fell, nursing staff were to activate a "Code Yellow," notify the patient's physician and family of the fall, complete a fall debrief form, and enter a report for follow up and tracking.

b. Nursing interviews conducted between the dates of 11/2/2020 and 11/4/2020 revealed nursing staff lacked understanding of what constituted a patient fall, and of the care and follow-up actions which were required after a patient experienced a fall.

i. On 11/2/20 at 1:39 p.m., an interview was conducted with RN #1. RN #1 stated the "Code Yellow" facility alert system was used if a patient experienced a fall event. RN #1 stated the "Code Yellow" alert was used throughout the facility to notify the nursing supervisor, the physician and other staff members if a fall occurred.

ii. On 11/3/20 at 4:00 p.m., an interview conducted with RN #2 revealed when a patient fell, staff did not always activate the "Code Yellow" facility alert system. RN #2 stated if a patient fell on the protective floor mat or if the patient did not sustain an injury, the nurse did not have to activate the "Code Yellow" alert system. She stated if staff did not activate a "Code Yellow" alert, the patient's physician or the patient's family were not notified if a patient fell.

iii. On 11/3/20 at 7:44 a.m., an interview was conducted with RN #3. RN #3 stated if a patient fell on a protective floor mat, it was not deemed as a fall. She stated since she did not consider this to be a fall, she did not activate the "Code Yellow" alert system or file an report if a patient fell on the floor mat.

iv. On 11/4/20 08:19 a.m., an interview was conducted with RN #4. RN #4 stated if a patient fell on their knees or their buttocks, then a "Code Yellow" alert was activated. She stated when a patient experienced a fall, the nurse performed a post-fall physical assessment, and noted any new bruises or abrasions. RN #4 stated the assessment was documented in the patient's medical record, and the staff would notify the nursing supervisor of the patient's fall.