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Based on interview, record review, and policy and procedure review the facility failed to ensure a safe care setting for 1 of 4 sampled patients, Patient #3.

Findings:

Based on interview, record review, and policy and procedure review the facility failed to ensure the implementation of their policy and procedures to provide a reassessment as determined by the patient's needs for 1 of 4 sampled patients, Patient #3.

Findings:

Review of Patient #3's medical record revealed the patient was a fall risk which required a sign on the door, a yellow wrist band, and both chair/bed alarms. The Morse Fall Risk documentation revealed a score of 60; 60 and greater indicated a high risk for falls.

Review of the nurse's note dated 09/18/18 at 4:39 PM revealed Patient #3 was found on the floor holding onto the bedside table. Chair alarm was underneath his (sic) bottom, plugged in, but not turned on. Patient #3 was very confused and lethargic. Patient had small skin tear on back of head, and left shoulder blade. Patient continued to be lethargic once in bed.

During an interview on 04/09/19 at 3:15 PM, with Staff G, RN (Registered Nurse) she stated the expectations are that chair alarms should be underneath the patient and plugged in.

Review of the facility's policy and procedure titled "Adult Fall Prevention Procedures and Guidelines" on page 3 read standardized High Risk Fall interventions should be implemented for all high fall risk patients. Use of bed/chair check device at all times while in bed or chair. Immediate response of all available staff is required upon bed/chair alarm activation to ensure patient safety.