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Based on medical record review, policy review and interview, nursing staff did not ensure the nursing care plan was updated and interventions were implemented related to fall precautions for Patient #1.

Findings:

Review of nursing flowsheet dated 10-1-15 at 12:09 PM (note prior to fall) revealed Patient #1 was disoriented to place and time with poor safety awareness. He has a history of falls, is weak and overestimates/forgets limitations. He uses ambulatory aids. Morse Fall Risk level is High (45 and higher). The bed is in lowest position with wheels locked, side rails are up ¾, bed wheels locked and chair wheels locked. He is able to use the call light and the over bed table is in reach. Fall Risk Interventions SCORE is >24. His room is close to the nursing desk, assistive devices are in reach and the bed alarm is on. A toileting plan is established. He has nonskid footwear and ruby slippers. A chair alarm is not indicated. Bedside observation monitoring is required.

Review of nursing note dated 10-1-15 at 11:45 PM (late entry) revealed Patient #1 was not placed on an alarm (chair) by previous shift and ambulated to doorway where he fell on his right side. Last fall risk score was 2 and interventions included use of bed/chair alarms.

Review of policy #10.23 "Inpatient Fall and Injury Prevention" last reviewed 4-15 revealed admitted adult patients are assessed for fall and injury risk and an individualized plan of care is established based on patient specific risk factors. This assessment and plan are to be completed and documented on the appropriate flow sheet/location in the electronic medical record (EMR) in the patient record by a registered professional nurse daily. The plan of care includes individualized interventions to minimize preventable falls and injuries and is reviewed each shift and updated based upon shift assessment and patient's status.

Interview with Staff # 6 on 8-19-16 at 01:30 PM revealed the patient had a 1:1 sitter but it was discontinued because the patient was more re-directable.

Phone interview with Staff # 18 on 8-24-16 at 11:25 PM indicated Patient #1 was moved from the bed to the chair. The chair alarm was not put on Patient # 1 ' s chair and should have been. It should have been documented that Patient #1 was moved to the chair.

Phone interview with Staff # 5 on 8-29-16 at 11:00 AM indicated that the individualized interventions/prevention guidelines described in policy #10.23 "Inpatient Fall and Injury Prevention" are the fall risk interventions in the patient's medical record.