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Based on record reviews and interviews, the facility failed to ensure that nursing staff documented accurate assessments and events that occurred for 1 of 1 patients (Patient #1) reviewed. This deficient practice placed all patients in the facility at high risk for undetected, untreated serious illness and/or injury.

Findings included:

Record review of the physician's progress notes for Patient #1, dated 10/09/2023 at 1:35 p.m. revealed the following information:

36-year-old male with a past medical history of a Status Post (s/p) craniotomy in the past, hypertension, PEG tube insertion who presented from outside ER with altered mental status and laboratory findings initially concerning for sepsis. He was intubated at the outside ER. So far infectious work-up has been negative. However history provided by the sister Indicates that he likely had a seizure. He has been extubated and is now on minimal amounts of nasal cannula. s/p VP shunt placed on 10/3/2023.
Patient was seen in room 585 and he was more awake and alert today. Able to follow simple commands. RN reported that the patient had a fall earlier this morning ... Magnetic Resonance Imaging (MRI) of head-showed prior infarcts but nothing new. Overnight the patient became agitated that required physical restraints. Currently calm, will Discontinue (DC) physical restraints and monitor. Change Seroquel to 100 mg at bedtime. No reported head injury however will repeat Cat Scan (CT) of head without contrast.

Record review of the nurse's notes for Patient #1, dated 10-08-2023 to 10-10-2023, revealed that patient #1 was considered a (code Yellow) fall risk (high risk). Further review revealed no evidence that nursing staff had performed a post fall assessment of Patient #1, obtained routine vital signs, or post fall neuro-checks on patient #1 after his reported fall on 10/09/2023.

Record review of the facility policy entitled: Falls Prevention Protocol (RM-PS-07), revised 08/2023, revealed the following:

D. Post-Fall Management

1. Assess for injury (e.g., abrasion, contusion, laceration, fracture, head injury, bleeding).
2. Activate RRT if change in patient condition post-fall. Primary nurse leads post-fall huddle.
3. Obtain radiologic studies and lab tests as indicated by physician or licensed practitioner.
4. Document the fall in the EMR using the Nursing Narrative Ad-Hoc form.
5. Complete Post-Fall Assessment Form and return to immediate supervisor for review/follow-up.
6. Supervisor ensures form is complete and is forwarded to Quality Department.
7. Obtain vital signs (including neuro checks if applicable) and a physical assessment after every fall
a. Every 30 min x4, every 2 hours x2 then per unit routine.
b. If vital signs are critical or the patient is deteriorating, continue vital signs every 15 minutes and call the physician and the Rapid Response Team.
c. If possibility of head injury, include Neuro Checks q 1 hour x 4 hours.
8. Notification of fall (document in Frequent Assessments > Notification in the Electronic Medical Record [EMR]):
a. Physician
b. Patient's emergency contact
9. Code Yellow response team conducts a debriefing huddle using the Post-Fall Assessment Form (90448800)

In an interview conducted on 01/31/2024, at 2:35 p.m. the facility Director of Accreditation and Chief Nursing Officer both verified the above findings and the facility's non-compliance.