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A. Based on observation, document review and interview, it was determined that for 5 of 5 patients' (Pt. #1, Pt. #2, Pt. #3, Pt. #4 and Pt. #5) clinical records reviewed and/or observed for nursing care, the Hospital failed to implement and/or document the fall interventions, to ensure a registered nurse supervised and evaluated the patients' care.

Findings include:

1. On 3/21/2023 from approximately 10:00 AM through 11:30 AM, an observational tour of the Hospital's CCU (coronary care unit) was conducted. During the tour, a signage was observed indicating that Pt. #2 was high risk for fall. Pt. #2 was not wearing a fall identification bracelet.

2. On 3/21/2023, the Hospital's policy titled, "Fall Prevention and Response" (approved on 10/2021) was reviewed and required, " ... Policy: 1. Prevention of patient falls is the responsibility of every member of the (Name of the Hospital) ... Procedure ... A. Adult Fall Assessment and Interventions ... 4. Patients assessed using Morse Scale (fall assessment tool) will be determined... (score of) 24 to 45 is medium risk.. greater than 45 the patient is high risk ... Adult patients who have been identified as low fall risk will be placed on universal fall precautions which includes: 1. Conduct purposeful rounding every hour.... 5. Bed or carts will be kept in low position with brakes on... Adult Patients who are moderate to high risk of falls will be placed on universal fall precautions plus the following: 1. A fall precaution sign will be placed in close proximity to the patient ... 2. Place a fall identification bracelet on the patient's arms unless contraindicated.... 5. Bed exit alarms/chair alarms will be utilized for patients identified as high risk for falls when appropriate ..."

3. On 3/21/2023, the Hospital's Job Description for Registered Nurse (undated) included, " ... Typical Duties ... Documents all nursing... treatments ... interventions and patient outcomes ..."

4. On 3/21/2023, the Hospital's policy titled, "Fall Prevention Program" (approved on 4/2018) included, "... Appendix A... I. Assessment... A. Adults... 4. Adult Risk Assessment... High Risk (Morse Fall score equal to or greater than 51)... II. Interventions to Reduce Likelihood of Falling and Injury... B. Beds will be kept in low position... III. Patients classified as high risk for falls... Place a fall identification bracelet... Bed exit alarms..."

5. On 3/21/2023, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted on 04/26/2019 due to heart failure. On 4/26/2019 at 8:00 PM, 4/26/2021 at 11:31 PM, 4/27/2019 at 4:00 AM, and 4/27/2019 at 8:00 PM, the nursing fall risk assessment scores for Pt. #1 were between 60 to 90. The clinical record lacked documentation of the following fall interventions: bed was kept in low position, placement of fall identification bracelet, and utilization of bed alarms.

6. On 3/21/2023, the clinical record for Pt. #2 was reviewed. On 3/19/2023, Pt. #2 was admitted to the Hospital's CCU due to bradycardia (low heart rate). On 3/22/2023 at 12:00 MN, the nursing fall risk assessment score for Pt. #2 was 35. The clinical record lacked documentation of the following fall interventions: purposeful rounding every hour, placement of fall identification bracelet and utilization of bed alarms.

7. On 3/21/2023, the clinical record for Pt. #3 was reviewed. On 3/20/2023, Pt. #3 was admitted to CCU due to elevated blood pressure and possible heart failure. On 3/21/2023 at 3:00 AM, 3/21/2023 at 8:00 PM and 3/22/2023 at 4:00 AM, the nursing fall risk assessment scores for Pt. #3 was 60. The clinical record lacked documentation of the following: purposeful rounding every hour, placement of fall identification bracelet, bed was kept in low position, and utilization of bed alarms.

8. On 3/21/2023, the clinical record for Pt. #4 was reviewed. Pt. #4 was admitted on 3/18/2023 with paroxysmal atrial fibrillation (heart rhythm disorder) and hypertension (high blood pressure). On 3/20/2023 at 8:00 PM, 3/21/2023 at 3:41 AM and on 3/21/2023 at 8:00 PM, the nursing fall risk assessment scores for Pt. #4 was 35. The clinical record lacked documentation of the following interventions: placement of fall identification bracelet, bed was kept in low position, and utilization of bed alarms.

9. On 3/21/2023, the clinical record for Pt. #5 was reviewed. Pt. #5 was admitted on 3/19/2023 due to chest pain. On 3/19/2023 at 8:00 PM, the nursing fall risk assessment score for Pt. #5 was 60. The clinical record lacked documentation of the following: purposeful rounding every hour, placement of fall identification bracelet, bed was kept in low position, and utilization of bed alarms.

10. On 3/21/2023 at approximately 10:15 AM, interviews were conducted with E #3 (CCU RN/Registered Nurse) and E #4 (Charge Nurse CCU). E #3 and E #4 stated that all patients in the CCU are considered as high risk for falls due to their underlying heart conditions. E #4 stated that all patients should have a fall identification bracelet at all times. During the clinical record reviews for Pt. #2, #3, #4 and #5, E #3 stated that documentation of the fall interventions were incomplete.

B. Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #10) clinical records reviewed due to falls, the Hospital failed to ensure that the registered nurse (RN) evaluated the nursing care for each patient by failing to document a fall reassessment.

Findings include:

1. On 3/21/2023, the Hospital's policy titled, "Fall Prevention and Response" (approved on 10/2021) was reviewed and required, " ... Policy... 5. All adult patients... are evaluated upon hospital admission and then each shift by an RN to determine their risk of falling... Procedure/Process A. Adult Fall Assessment and Interventions. 1. Every inpatient is assessed upon admission using the Morse Scale for adults... 3. Reassessment of fall risk occurs every eight (8) hours..."

2. On 3/22/2023, the Hospital's fall log from January 2023 through March 2023 was reviewed. The log included an incident of fall for Pt. #10.

3. On 3/22/2023, the clinical record for Pt. #10 was reviewed. Pt. #10 was admitted to the Hospital on 3/16/2023 with a diagnosis of anoxic brain injury (lack of oxygen in the brain). The clinical record indicated that a fall risk assessment was not conducted between 3/18/2023 at 8:00 PM and 3/19/2023 at 12:00 PM (approximately 16 hours).

4. On 3/22/2023 at approximately 10:00 AM, findings were discussed with E #7 (Nursing Director of Quality). E #7 stated that a fall reassessment should be conducted every eight hours.

C. Based on document review and interview, it was determined that for 1 of 5 patients' (Pt. #1) clinical records reviewed for patient care, the Hospital failed to ensure that a Registered Nurse assessed and evaluated the nursing care of each patient.

Findings include:

1. The Hospital's "Job Description for Clinical Nurse I" (dated 12/1/2017) was reviewed and required, " ... responsible for providing and coordinating safe, effective individualized nursing care to critically ill patients ... ongoing assessment ... Documents all nursing assessments ... interventions ..."

2. The clinical record of Pt. #1 was reviewed on 03/21/2023. Pt. #1 was admitted on 04/26/2019 due to heart failure. On 4/27/2019 at 8:18 AM, the clinical record included a physician's order for a neurological checks every 15 minutes. On 4/27/2019, the clinical record lacked every 15 minutes neurological checks from 1:15 PM to 1:45 PM; 2:15 PM to 2:45 PM, and from 3:15 PM to 3:45 PM.

3. On 3/22/2023 at approximately 11:15 AM, an interview was conducted with the Director of Quality (E #8). E #8 stated that the assigned nurse should document all care provided to patiens in the clinical record preferably in real time or prior to end of their shift. E #8 confirmed that there were gaps in the 15-minute neurological assessments.