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Based on observation, interviews, record review, and policy review the facility failed to provide a safe environment that includes notification of family in timely manner of change in condition for 1 ( patient #1) and supervison for falls for 2 ( patient #1 and #8) of ten patients reviewed.

Findings:

Patient #1: was admitted to the Intensive Care Unit (ICU) on 04/28/2015 for acute respiratory failure, stabilized and was transferred to the Cardiac/telemetry floor on 04/29/2015. She was on high risk fall precautions, on Ativan 0.5 mg for anxiety/depression, and Tramadol (Ultram) 50 mg twice a day (BID) for chronic neck pain.

During an interview on 06/26/2015 at 1:00 PM,with the daughter of patient #1, revealed that she was not notified of her mother ' s fall, hip fracture and the test ordered for her mom as the Computed Tomography (CT) of the brain and a X-ray of the right hip until after these procedures were completed. When she called the facility herself to speak to the nurse inquiring about her mother, was than she was notified of what had happened.

During an interview on 06/25/2015 at 1:30 PM with Registered Nurse A (RN) revealed that when asked if the bed alarm was on for patient #1 on 04/30/2015, she stated " the bed alarm was not on or sounding for patient #1 when I found her on the floor on 04/30/2015 at approximately 8:00 AM."

During an interview with Dr. A, on 06/25/2015, revealed that she did not receive a call from nursing staff on the morning of 06/30/2015 for patient #1 for pain medications, and if she had received a call she would have returned it, and if she is unavailable that she has additional physician coverage that could have been contacted to obtain an order for pain medications.

Review of Nursing Notes, (Clinical Documentation Record), dated 04/29/2015 at 9:00 PM, revealed a Nursing Assessment for: Fall precautions. Patient encourage to call for assists when need but is forgetful. On Fall Protocol. Frequent rounding. Additional fall precautions include signs outside the door, armbands and on chart.
Further fall precautions also included assisting with both mobility and toileting. Having patient have non slip footwear on, and bed alarm.

Review of nurse ' s notes on 04/30/2015 at 6:00 AM revealed that patient #1's bed alarm was ringing. Patient was up out of bed, almost pulled intravenous site again. Patient stated that she was having anxiety, and she can't help it. Patient encouraged to go to bed, and this nurse helped the patient back to bed, and gave Ativan 0.5 mg to help patient's anxiety. Charge nurse made aware and consulted situation throughout the night regarding patient.

Further review of nurse ' s notes on 04/30/2015 at 8:00 AM revealed that patient #1 was found on the floor near the white information board in her room by staff. Physician notified and orders for a Computed Tomography (CT) of the brain and a X-ray of the right hip due to the patient's complaint of pain in the head and right hip pain, which the X-ray confirmed a Fracture of the right Femur. Post fall assessment started.

Patient # 8:

Patient # 8 was admitted to the emergency room for a complaint of a respiratory problem. patient # 8 was then admitted to the respiratory floor.

Observation, record review and interview on 06/25/2015 at 10:00 AM on the Cardiac/Telemetry Floor of patient #8 revealed that she was on fall precautions, but there was not any signage posted on her door to alert staff.

During an interview on 06/25/15 at 10:15 AM, with patient #8's nurse, confirmed that there was not any signage on her door alerting that she was a fall precaution, and that should have been, since she is at risk for falls.

Record review of the facility's policy titled, "Fall Prevention" dated 06/15, showed that a fall risk assessment is to be done by staff on admission, every shift, change in patient condition and when an a fall occurs. IF a patient is assessed to be at high risk for a fall, additional interventions includes sign at door. Should a fall occur both the Physcian and family should be notified.

Based on observations, interviews and record reviews, the registered nurse(s) failed to evaluate the care provided and to implement appropriate nursing measures to prevent falls for 2 of 10 patients( Patient #1& #8), and to obtain a physician order to provide pain medication timely for 1 patient ( patient#1) of 10 reviewed.

Findings:

Patient #1: was admitted to the Intensive Care Unit (ICU) on 04/28/2015 for acute respiratory failure, stabilized and was transferred to the Cardiac/telemetry floor on 04/29/2015. She was on high risk fall precautions, on Ativan 0.5 mg for anxiety/depression, and Tramadol (Ultram) 50 mg twice a day (BID) for chronic neck pain.

During an interview on 06/25/2015 at 1:30 PM with Registered Nurse A (RN) revealed that when asked if the bed alarm was on for patient #1 on 04/30/2015, she stated " the bed alarm was not on or sounding for patient #1 when I found her on the floor on 04/30/2015 at approximately 8:00 AM."

During an interview with Dr. A, on 06/25/2015, revealed that she did not receive a call from nursing staff on the morning of 06/30/2015 for patient #1 for pain medications, and if she had received a call she would have returned it, and if she is unavailable that she has additional physician coverage that could have been contacted to obtain an order for pain medications.

During an interview on 06/26/2015 at 1:10 PM with the daughter of patient #1, revealed that her mother has been on Tramadol 50 milligrams twice a day (BID) before she entered this facility, and has been on this medication for a long time for chronic neck pain. She further stated that her mother did not receive and pain medication coverage ordered to elevate her pain until late that afternoon on 04/30/2015.

Review of the nursing documentation of 04/30/2015 for patient #1 did not reveal that she received any pain medication to elevate her pain until a telephone order at 3:05 PM that was obtained for Morphine Sulfate 1 mg. and was administered with a pain scale 7 to 10.
Six and one half (6 1/2) hours after her fall and three and on half (3 1/2) hours after confirmation of a right fracture of her femur.

Review of nursing notes, (Clinical Documentation Record), dated 04/29/2015 at 9:00 PM, revealed a Nursing Assessment for: Fall precautions. Patient encourage to call for assists when need but is forgetful. On Fall Protocol. Frequent rounding. Additional fall precautions include signs outside the door, armbands and on chart. Further fall precautions also included assisting with both mobility and toileting. Having patient have non slip footwear on, and bed alarm.

Review of nurse' s notes on 04/30/2015 at 6:00 AM revealed that patient #1's bed alarm was ringing. Patient was up out of bed, almost pulled intravenous site again. Patient stated that she was having anxiety, and she can't help it. Patient encouraged to go to bed, and this nurse helped the patient back to bed, and gave Ativan 0.5 mg to help patient's anxiety. Charge nurse made aware and consulted situation throughout the night regarding patient.

Further review of nurse ' s notes on 04/30/2015 at 8:00 AM revealed that patient #1 was found on the floor near the white information board in her room by staff. Physician notified and orders for a Computed Tomograpy (CT) of the brain and a X-ray of the right hip due to the patient's complaint of pain in the head and right hip pain, which the X-ray confirmed a Fracture of the right Femur. Post fall assessment started

Patient # 8 was admitted to the emergency room for a complaint of a respiratory problem. Patient # 8 was then admitted to the respiratory floor.

Observation, record review and interview on 06/25/2015 at 10:00 AM on the Cardiac/Telemetry Floor of patient #8 revealed that she was on fall precautions, but there was not any signage posted on her door to alert staff.

During an interview on 06/25/15 at 10:15 AM, with patient #8's nurse, confirmed that there was not any signage on her door alerting that she was a fall precaution, and that should have been, since she is at risk for falls.

Record review of the facility's policy titled, "Fall Prevention" dated 06/15, showed that a fall risk assessment is to be done by staff on admission, every shift, change in patient condition and when an a fall occurs. IF a patient is assessed to be at high risk for a fall, additional interventions includes sign at door. Should a fall occur both the Physician and family should be notified.

Based on observation, staff interviews and record review, the nursing staff failed to provide supervision to two of ten (#1 and # 8) sampled patients of patient care needs for fall precautions and pain medications.

Findings:
Patient # 1:
During an interview on 06/25/2015 at 1:30 PM with Registered Nurse A (RN) revealed that when asked if the bed alarm was on for patient #1 on 04/30/2015, she stated " the bed alarm was not on or sounding for patient #1 when I found her on the floor on 04/30/2015 at approximately 8:00 AM."

During an interview with Dr. A, on 06/25/2015, revealed that she did not receive a call from nursing staff on the morning of 06/30/2015 for patient #1 for pain medications,or that patient had a fall. If she had received a call she would have returned it, and if she is unavailable that she has additional physician coverage that could have been contacted to obtain an order for pain medications.

Review of Nursing Notes, (Clinical Documentation Record), dated 04/29/2015 at 9:00 PM, revealed a Nursing Assessment for: Fall precautions. Patient encourage to call for assists when need but is forgetful. On Fall Protocol. Frequent rounding. Additional fall precautions include signs outside the door, armbands and on chart.
Further fall precautions also included assisting with both mobility and toileting. Having patient have non slip footwear on, and bed alarm.

Review of nurse ' s notes on 04/30/2015 at 6:00 AM revealed that patient #1's bed alarm was ringing. Patient was up out of bed, almost pulled intravenous site again. Patient stated that she was having anxiety, and she can't help it. Patient encouraged to go to bed, and this nurse helped the patient back to bed, and gave Ativan 0.5 mg to help patient's anxiety. Charge nurse made aware and consulted situation throughout the night regarding patient.

Further review of nurse ' s notes on 04/30/2015 at 8:00 AM revealed that patient #1 was found on the floor near the white information board in her room by staff. Physician notified and orders for a Computed Tomography (CT) of the brain and a X-ray of the right hip due to the patient's complaint of pain in the head and right hip pain, which the X-ray confirmed a Fracture of the right Femur. Post fall assessment started.

Review of Nursing Notes, (Clinical Documentation Record), dated 04/29/2015 at 21:00 PM revealed a Nursing Assessment for: Fall precautions which included a bed alarm. patient encourage to call for assists when need but is forgetful. On Fall Protocol. frequent rounding.

Review of nurses notes on 04/30/2015 at 8:00 AM revealed that patient #1 was found on the floor near the white information board in her room by staff. Physician notified and orders for a Computed Tomograpy (CT) of the brain and a X-ray of the right hip due to the patient's complaint of pain in the head and right hip pain, which the X-ray confirmed a fracture of the right femur. Post fall assessment started.

During an interview on 06/25/2015 at 2:30 PM with Registered Nurse #1 (RN) revealed that when she was asked if she called patient #1's daughter right after her fall and before she received the CT and X-ray of the right hip, she stated "I called her afterward, later that morning around 11:00 AM."

During an interview on 06/25/2015 at 2:30 PM with Registered Nurse A, she stated "I was told by the night shift nurse that the bed alarm was on for patient #1, and I did not check the alarm myself to see if it was on."

During an interview on 06/25/2015 at 1:30 PM with Registered Nurse #B revealed that when asked if the bed alarm was on for patient #1 on 04/30/2015, she stated " the bed alarm was not on or sounding for patient #1 when I found her on the floor on 04/30/2015 at approximately 8:00 AM."

During an interview on 06/26/2015 at 1:00 PM, with the daughter of patient #1, revealed that her mother has been on Tramadol 50 milligrams twice a day (BID) before she entered this facility, and has been on this medication for a long time for chronic neck pain. She further stated that her mother did not receive and pain medication coverage ordered to elevate her pain until late that afternoon on 04/30/2015.

Review of the nursing documentation of 04/30/2015 for patient #1 did reveal that she did not receive any pain medication to relieve her pain until a telephone order at 3:05 PM, that was obtained for Morphine Sulfate 1 mg. Which was administered with a pain scale 7 to 10.
Six and one half (6 1/2) hours after her fall and three and on half (3 1/2) hours after confirmation of a right fracture of her femur.

patient # 8:
Observation on 06/25/2015 at 10:00 AM on the Cardiac/Telemetry Floor of patient #8 revealed that she was on fall precautions, but there was not any signage posted on her door to alert staff.

During an interview on 06/25/15 at 10:15 AM with patient #8's nurse confirmed that there was not any signage on her door alerting that she was a Fall Precaution, and that should have been, since she is at risk for falls.

Review of the facility's Policy and procedure titled Fall prevention revealed the following:
if patient has fall risk, an assessment will be conducted each shift, change in condition, and when a fall occurs. There are additional interventions for high risk falls as an alert, which is a an armband, signs and flagging the chart. There are other interventions used as a bed alarm. should a fall occur, notify Physcian and family.