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Based on review of facility policy and procedures, medical record review, unit observation, and patient and staff interviews, the facility staff failed to identify and keep a high fall risk patient safe in 1 of 4 sampled patients (Patient #18).

The findings include:

Review on 02/16/2017 of facility policy and procedures "Fall Assessment, Prevention and Management -Adult Inpatients" (Revised August 25, 2015) revealed, "I. SCOPE/PURPOSE All adult inpatients are assessed for risk of falls. ...IV. EQUIPMENT -Bed alarms and/or other fall monitoring devices -Assistive equipment/devices -Yellow armband V. PROCEDURE ...3 Patients are reassessed for fall risk...d. Change in patient condition ..."

Medical record review on 02/15/2017and 02/16/2017 revealed Patient #18 was a 52 year old male patient admitted on 01/25/2017 with a diagnosis of lymphoma (cancer of blood cells). Review revealed his admitting Morse Score (the fall risk screening method used at the facility) on 01/25/2017 at 2027 was 20 (low/moderate fall risk) and remained 20 until 02/03/2017 at 0010. Review from 02/03/2017 at 0826 through 02/07/2017 at 1220, Patient #18's Morse Score was 35 (low/moderate fall risk). Review from 02/07/2017 at 1220 through 02/10/2017 at 1806, Patient #18's Morse Score was 45 (high fall risk). On 02/10/2017 at 2010 the Morse Fall Score was decreased to 35 (low/moderate fall risk), and remained at 35 until 02/15/2017 at 1200 after Patient #18 fell. The score was then increased to 45. Review of "Physical Therapy - Initial Evaluation" dated 02/07/2017, revealed, "PT (physical therapy) findings include inability to mobilize OOB (out of bed) without symptomatic orthostatic hypotension (abnormally low blood pressure). Pt (patient) would benefit from PT to safely progress activity. Pt (sic) currently recommends home with 24 hour supervision at d/c (discharge). PT Problem list: Decline in ambulation; Decreased ADL function; Decreased functional mobility; Decreased activity tolerance; Gait instability; Fall risk; Impaired balance. Treatment Diagnosis: Difficulty walking. ...Pt assisted OOB and started to ambulate in room. He then c/o (complained of) starting to feel dizzy. Pt directed to return and sit on bed. When he got close to the bed, he became disoriented and unable to find the edge of the bed and required min A (minimum assistance) to physically direct him. Once he was sitting, pt became unresponsive. PT immediately positioned the pt (patient) supine and yelled for help. Pt immediately became alert and oriented to loud voice but had no memory of the incident. ...While pt was having his BP (blood pressure) taken in standing, he again became non-responsive and was quickly put into the supine (lying down) position." Review of "Physical Therapy - Treatment" note on 02/10/2017 at 1452 indicated no change in the "PT Problem List". Continued review of the note revealed " Educated pt and girlfriend on performing activity in moderation as pt is able and to increase time with activities to prevent orthostatic hypertension (sic) and increase safety with staying close to a seat or EOB (end of bed) if he feels weak, or feels like he may pass out. Instructed pt to continue with ambulation as tolerates (sic) with nsfg (sic) (nursing) or girlfriend to increase activity level and strength as well as performing sit<>stands (sic) (from sitting to standing activity) x10 or x15 as patient tolerates." Review of "Physical Therapy - Treatment" note on 02/15/2017 at 1108 indicated " ...pt stumbled backwards but regained bal (sic) and reports 'I'm all right' followed by B (bilateral) knee buckle, pt gently lowered to the floor and positioned against the wall, PTA (Patient Therapy Assistant) # 1 called for help, +2 to get pt to his feet and into chair, nursing called, BP 92/47, pt take (sic) back to his room in recliner."

Observation on 02/15/2017 from 1100 to 1126 on the hematology/oncology (blood/cancer) unit, revealed Patient #18 sitting in a chair being prepared for a blood product transfusion. Observation revealed Patient #18 did not have a yellow armband on, and did not have a chair alarm in place. Continued observation revealed a chair alarm module hanging on the wall in the room. The alarm module was not connected to the chair pressure sensor.

Observation on 02/15/2017 at 1130 upon return to Patient #18's room revealed the patient sitting on the floor beside his bed, and the primary nurse (RN #2) attempting to assist him into his bed. A "Code Lift" was requested by RN #2 over the room intercom, and Patient #18 was assisted back to his bed.

Interview on 02/15/2017 at 1120 with Patient #18 revealed he had been ambulating in the room without assistance. The interview revealed that during physical therapy earlier that morning, Patient #18 became weak while attempting to negotiate stairs in preparation for discharge. Continued interview revealed that Patient #18's knees buckled and he was backed against the wall and assisted to a sitting position by the therapist. Patient #18 also related an earlier episode during this hospitalization in which he "passed out" while returning to bed, and was urgently assisted by staff into his bed.

Interview on 02/15/2017 at 1200 with RN #2 revealed that she was aware of the stairwell events earlier in the day, and high risk fall interventions were not in place at the time of the second event of that day. Further interview revealed that patient #18 was considered at high risk for fall after the second event of that day, and a fall huddle did occur.

Interview on 02/15/2017 at 1300 with PTA #1 revealed he was familiar with Patient #18 and performed the initial assessment. PTA #1 was with Patient #18 on 02/07/2017 when the patient became dizzy, was assisted to the bed, and briefly lost consciousness. Based on the initial assessment Patient #18 was considered at high risk for fall, but since the patient did not contact the floor, the incident was not considered a fall. Interview with PTA #1 revealed he also accompanied Patient #18 on 02/15/2017, when the patient's knees buckled and the patient was assisted to the floor. PTA #1 indicated that the events of the 02/15/2017 morning session had been relayed to the primary nurse (RN #2), but a post fall huddle was not conducted because the event was not considered a fall.

Interview on 02/16/2017 at 1045 with AS (administrative staff) #3 and #4 revealed that falls education was provided to all clinical staff. Patient safety and fall prevention was a company-wide initiative. Nursing was the primary recipient of the education, but in the future all clinical staff would receive the falls education. Further interview revealed that all disciplines will be responsible for patient safety and would begin to perform post fall huddles.

Based on review of facility policy and procedures, medical record review, and staff interviews, the facility staff failed to implement high risk fall precautions for 1 of 4 sampled patients on high risk fall precautions (Patient #2).

The findings include:

Review on 02/14/2017 of facility policy and procedure "Fall Assessment, Prevention and Management -Adult Inpatients", revised August 25, 2015, revealed, "I. SCOPE/PURPOSE All adult inpatients are assessed for risk of falls. ...IV. EQUIPMENT -Bed alarms and/or other fall monitoring devices -Assistive equipment/devices -Yellow armband V. PROCEDURE ...3 Patients are reassessed for fall risk...d. Change in patient condition ..." Further review revealed, "...Morse Fall Scale Risk Level Guide...High Risk...45 and higher...Implement High Risk Fall Prevention Interventions...High Risk Fall Patients preventions interventions include...Bed/chair alarms on at ALL times..."

Review on 02/14/17 of facility policy and procedure "Restraints and Seclusion" reviewed 06/18/2016 revealed "...2. Type of restraint/seclusion - The type or technique of restraint or seclusion must be the least restrictive intervention tht will be effective to protect the patient, a staff member or others from harm....3. Sequence of least to most restrictive restraints:...d. Vest...6. Monitoring - The following will be monitored and documented every 2 hours (within 15 minutes before or after ) or more often if indicated by patient condition:...Circulation:...Skin condition:...Correct application of the restraint:..."

Closed medical record review on 02/14/2017 of the H&P (History and Physical) revealed, Patient #2 was a 92 year old female patient who presented to the ED (Emergency Department) on 12/18/2016 with "...Sudden altered mental status With confusion , headache and Garbled speech...." Review revealed Patient #2 had a history of mini-strokes and an abdominal aortic dissection with thrombus (a tear in the abdominal portion of the aortic blood vessel with blood clots). Review of the "Orders" by the Hospitalist #1 revealed, an order for "...Fall Precautions..." was written for the Patient #2 dated 12/18/2016 at 2157. Review revealed Patient #2 was admitted with a Morse Score of 85 to 100 during the hospital course of 12/18/2016 through 12/21/2016 indicating the need for high risk fall interventions to be implemented. Review of the "Orders" dated 12/19/2017 at 1739 revealed an initial order for a non-violent vest restraint with a clinical justification of self-harm. Review of the "...Flowsheet Data..." dated 12/21/2017 at 1800 by a RN #1 (Registered Nurse) revealed Patient #2 had the "...inability to follow directions..." and "...was attempting to get out of bed/chair..." Further review revealed the vest restraint was intact and Patient #2 's ..."Safety ensured. Review of the "Fall Interventions/Hourly Rounds by a CNA #1 (Certified Nurse Aide) dated 12/21/2017 at 1800 revealed Patient #2 was on high risk fall interventions and "...All Interventions..." were "... performed..." Review of the "...Flowsheet Data..." dated 12/21/2017 at 2000 by RN #1 revealed the patient's son was present in the patient's room. Further review revealed the patient had the "...inability to follow directions..." and "...was attempting to get out of bed/chair..." Further review revealed the vest restraint was intact and Patient #2 's ..."Safety ensured. Review of the "Fall Interventions/Hourly Rounds by RN #1 dated 12/21/2017 at 2000 revealed Patient #2 was on high risk fall interventions and the high risk fall intervention - bed alarm was not on. Review of a "Nursing Note" dated 12/22/2017 at 0100 by RN#1 revealed Patient #2 "...was found on the floor around 2030....Noted a swollen area on the back of the patient's head,...Patient at baseline- alert and oriented to person, place and year and easily confused....MD (Medical Doctor) paged and STAT CT (Cat Scan) ordered. Noted decreased LOC (Level Of Conscience) shortly after. RRT (Rapid Response Team - code blue team)...Patient's vitals continue to decline....Time of death declared at 2330..."

Interview on 02/06/2017 at 0915 with the primary RN #1 assigned to Patient #2 for the shift revealed the patient was alert and confused but not oriented. One of the patient's son was in the room and asked if he could speak with her. The interview revealed CNA #1 was in the room also assisting the patient. She stated she and the son stepped outside the room to talk while CNA #1 was getting the patient situated. He was moving her up into the bed which means the bed alarm was not on. The interview revealed later during the shift RN #1 was assisting another patient in another room when she was notified that Patient #2 had fallen. She returned to the Patient #2 's room to find her back in bed with assistance from other staff. The interview revealed there was not a bed alarm on but the bed alarm should have been on. Review revealed staff failed to keep Patient #2 safe.

Interview on 02/15/2017 at 1427 with the CNA #1 caring for Patient #2 prior to the fall revealed Patient #2 was confused at times and tried to remove the vest restraint. The interview revealed the son was in earlier and explained to the patient that she could not leave and she was at the hospital for the staff to help her. Interview revealed later during the shift CNA #1 was next door assisting another patient when he heard a crash. He went to the door and observed Patient #2 on the floor and the IV (Intravenous) pole on the floor. Interview revealed another CNA went into Patient #2 's room to assist her. Interview revealed he did not hear a bed alarm.

Interview on 02/15/2017 at 1438 with the NM #1 (Nurse Manager) for the unit which Patient #2 fell revealed the bed alarm was not on, but should have been on.

NC00124551