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Based on interview, record and policy review the facility failed to honor the rights of the patient and the patient's representative to make informed decisions regarding the patient's care by not providing notification of the patient's fall at the time of incident in 1 (SP#1) out of 4 sampled patients (SP).

The findings:

Review of sample patient (SP) #1 Physician's Emergency Department Notes dated 08/03/2018 revealed that patient presented to the emergency room for evaluation of abdominal pain. Family reports patient was seen at another facility a few times within the last 3 weeks where fluid was removed from his abdomen twice.

Review of SP#1 Emergency Department Part 1 dated 08/03/2018 revealed Morse Fall Risk assessment. Mental Status Morse: Oriented to own ability.

Review of SP#1 Nursing Notes dated 08/11/2018 revealed as per previous Registered Nurse patient had a fall, will like to monitor patient for bleed prior to giving heparin.


Review of SP#1 Nursing Department In-Patient Post Fall Review dated 08/11/2018 revealed a not witnessed, unanticipated fall. Morse Fall Scale Risk Screening Score at the time of fall was 45 and on admission was 35.

Review of SP#1 Physician Order Non-Violent Restraint dated 08/12/2018 and 08/29/2018 revealed Indication for restraint: unable to comprehend or follow directions to refrain from activities that can injure self; observed trying to climb out of bed when instructed not to do so; Cognitively impaired.


Interview with Staff B, Registered Nurse on 11/13/2018 at 11:32 AM revealed when a patient falls the physician is notified and orders are followed. The patient is reassessed and monitored per post-fall protocol. The family is notified.

Interview with Chief Nursing Officer on 11/14/2018 at 11:57 AM revealed that there was no documentation in the medical record that described the fall event or that the nurse notified the spouse of the patient's fall at the time of incident.

Review of Policy # 200.15: Falls Prevention and Resource Policy with last revision date of 02/12 and last review date of 09/18 revealed Post-Fall Management: Complete Post-Fall Assessment Form and return to immediate supervisor; Notification of fall: physician (if not previously called) and patient's emergency contact; Objective documentation in the medical record should include, but is not limited to: description of the fall episode to include: witnesses to the fall (if any), position in which the patient was found, assessment post-fall (changes in range of motion (ROM), neuro status, etc.), interventions initiated, persons notified and follow-up activities.