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Based on medical record reivew, facility investigation review, and interivew, the facility failed to notify the family of a patient fall and failed to document circumstances surrounding a fall, post fall assessment, and care rendered for one (#3) of eight patients reviewed.

The findings included:

Medical record review revealed patient #3 was admitted to the rehabilitation unit on July 25, 2011, with diagnoses to include adenocarcinoma of the Stomach, Pancreatitis, Abdominal Infection. Atrial Fibrillation, and Bradycardia (slow pulse). Continued medical record reivew revealed the patient was discharged on October 1, 2011, by ground van to a nursing facility in Florida, and the patient expired on October 10, 2011.

Review of a Minimum Data Set assessment dated July 25, 2011, revealed the patient required extensive assistance of two persons to transfer; extensive assist of one person for bathing, dressing, and grooming; had a foley catheter in place; and was continent of bowel.

Review of facility documents revealed an incident report dated September 27, 2011, at 10:45 p.m., in which the patient was found sitting on the floor beside the bed. Continued review revealed the bed alarm was on and side rails were up. Further review of the investigation revealed the staff were unable to account for the fact the patient was found on the floor when it required two people to transfer the patient. Continued review of the investigation revealed the section for "Family notified" was marked as "N" for no.

Review of nursing notes for September 27, 2011, revealed assessments completed and two hourly safety checks documented but there is no documentation of the patient falling out of bed; subsequent patient assessment; any emergency measures undertaken; or notification of physician and family.

Telephone interview with the Quality Manager on May 30, 2012, at 1:55 p.m., revealed the Quality Manager had spoken to the Director of Nursing about the incident. Continued interview revealed the Quality Manager noted there was no documentation of the fall in the nursing notes. Further interview revealed the Quality Manager spoke to the nurse involved concerning the lack of documentation.

Interview with the Director of Nursing (DON) on May 30, 2012, at 2:10 p.m., in the activity room, confirmed the patient's spouse was notified of the fall the next morning when the spouse came to visit the patient. Continued interview with the DON also confirmed the physician was not notified of the incident until the next morning. Further interview with the DON revealed the patient had a bed alarm but had disconnected the alarm. Continued interview with the DON revealed the patient required strong encouragement even to turn. Further interview revealed the patient was more alert during the day when visitors stopped by. Further interview with the DON revealed there is a section in the electronic charting for falls where all the needed information is to be entered. Continued interview with the DON confirmed there was no documentation in the nursing notes regarding the fall; post-fall assessment; emergency treatment required; or notification of family and physician and the DON confirmed this information should have been documented by the nurse.

Interview with the DON and Chief Nursing Officer (CNO) on May 30, 2012, at 2:30 p.m., in the activity room, revealed they have a "grab and go" system in place for patients at risk for falls which consists of a bag filled with non-skin stockings, yellow arm band, door signs, and a letter to the family. Continued interview with the DON revealed the nurse grabbed the bag on the way to complete the admission assessment and had everything needed. Further interview with the CNO revealed inservices were held after the incident regarding falls and appropriate documentation. Continued interview with the DON revealed falls were included as part of the facility's annual skills fair. Further interview with the CNO revealed the facility now had a falls team who met in the patient's room after a fall to assess what occurred; what caused the fall; and how to prevent future falls.

COMPLAINT #29470