HospitalInspections.org

Based on review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to notify POA (power of attorney) of a fall while at the facility for one patient (P) (P#1) of five patients reviewed when P#1 sustained a fall on 7/9/25.


Findings Included:


A review of medical records revealed that P#1 was admitted to the facility involuntarily (1013) on 7/4/25 at 4:25 p.m.


A review of the Intake Assessment: Conservator under the AR Assessment on 7/5/25 at 9:05 a.m. revealed documentation of a Power of Attorney (POA) with a note indicating the name of P#1 ' s family member.


A review of the Intake Assessment: Summary of Clinic under the AR Assessment on 7/5/25 at 9:05 a.m. revealed that P#1 ' s family member, who held his (P#1) power of attorney, reported his (P#1) medical history of dementia, and also noted that P#1 did not like being assisted by female staff for any aspect of his care.


Documentation under the emergency contact name on 7/5/25 at 9:09 a.m. revealed that P#1 ' s family member, who was also the POA was listed as P#1 ' s emergency contact.


Further review of P#1 ' s medical record revealed under the Post Injury/Fall Nursing Progress Notes, documentation by RN EE on 7/8/25 at 10:22 p.m., that P#1 was found yelling " HELP " and was found on the bathroom floor lying on the right side with the head up and shoulder down.


During an electronic medical record review at the facility on 9/8/25 at 1:30 p.m. with Chief Nursing Officer (CNO) LL, documentation revealed that the medical providers (NP CC and PSY DD) and the director of PI/Risk were informed of P#1 ' s fall. Documentation failed to reveal that P#1 ' s POA was informed about the incident.


A review of the facility ' s Incident log from 3/2/25 to 9/2/25 revealed an incident reported on 7/9/25 regarding P#1. Documentation by RN EE revealed that P#1 was found on the floor after he (P#1) yelled for help. Documentation revealed that P#1 was found lying on the right side with his head up and his shoulder down.

Further review of the incident report log revealed that P#1 was assisted to a sitting position, and he was able to answer questions and give a full spelling of his name. Documentation also revealed that the doctor was notified. Documentation failed to reveal that P#1 ' s POA was notified.


A review of the facility ' s policy titled "Patient Rights ," last reviewed 1/2025 revealed that patients had the right to be free of abuse and neglect and receive care in a setting.


A review of the facility ' s policy titled "Incident Reporting," Policy #NR#73, last reviewed 1/2025, stated that only the employee who is directly involved in the occurrence or incident, either through witnessing the event or being told by a visitor that an event has occurred, should initiate and document on the Incident Report form. This should be done immediately after the incident occurred (if witnessed) or as soon as one becomes aware of such an occurrence (receiving information from another person).
Once an incident has been observed or reported, the patient's attending physician, the Clinical Services Coordinator, and the patient's parent or legal guardian (if a minor or under guardianship) should be notified.
The legal guardian must be notified of all unusual incidents. The information should be shared by the charge nurse unless a decision was made that it would be more appropriate by the therapist or physician. The report should be made as soon as possible, and requested for any necessary follow-up (i.e., tests, medical treatment, etc).
The nurse completed the nursing flow sheet every shift and documented progress notes.


An interview took place in the facility ' s conference room on 9/8/25 at 3:30 p.m. with Program Nurse Manager (PNM) BB, who stated that she could not recall P#1, nor the incident. PNM BB stated that if a patient sustained a fall, a full assessment would be done by the nurse, and the MD (medical doctor) would be notified. PNM BB stated that if the patient had obvious injuries or bleeding, then the patient would be sent out to the ED (emergency department) for further evaluation, and she (PNM BB) would expect that the patient ' s POA or legal guardian on file would be notified.


An interview took place in the facility ' s conference room on 9/9/25 at 10:00 a.m. with Nurse Practitioner (NP) CC, who stated that he could not recall P#1, but he usually received a lot of calls from the nurses regarding patients ' falls. NP CC stated that based on the nursing assessment and nursing judgement coupled with the questions he (NP CC) would ask via the phone (if the call was outside hours), the patient may be sent out to the ED for further evaluation. NP CC also stated that he would only see the patient post-fall if there was a consultation that the patient needed to be seen by the medical team, or if the patient sustained an injury, or had any acute issues, as the psychiatrist always did a daily round on all patients.


An interview took place in the facility ' s conference room on 9/9/25 at 10:30 a.m. with Psychiatrist (PSY) DD, who stated that he could not recall P#1. However, if there was a fall on the unit, based on the assessment parameters by the nursing team and evaluation by the medical providers, the medical team could decide to send the patient out for further evaluation, and he (PSY DD) would expect the nursing team to notify the patient ' s POA, as that was the nurses ' responsibility.


An interview took place in the facility ' s conference room on 9/9/25 at 1:45 p.m. with Mental Health Technician (MHT) JJ, who stated that he could not recall P#1. However, if a patient sustained a fall, either witnessed or unwitnessed, the protocol would be to inform the nurse and obtain vital signs from the patient. MHT JJ stated that the nurse would then notify the doctor and take it from there.


A telephone interview took place on 9/10/25 at 9:00 a.m. with Registered Nurse (RN) GG, who stated that she could not recall P#1or the incident. RN GG stated that if a patient had a fall on the unit, the protocol would be to take a set of vital signs and inform the provider to obtain the next set of orders. The provider would decide whether to send the patient out or not based on the parameters of the vital signs and nursing assessment.


A telephone interview took place on 9/10/25 at 9:30 a.m. with Nursing Supervisor (NS) FF, who stated that if a patient had a POA, and it had been determined at the patient ' s initial assessment that the POA could be given updates about the patient ' s care, then she (NS FF) would expect that the patient ' s POA would also be informed if the patient had an incident.