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Based on clinical record review, policy review and interview, it was determined the facility failed to ensure there was a physician's order for one (#10) of one restrained patient reviewed. The failed practice had the potential to affect all patients admitted to the facility who were placed in restraints. Evidence follows:

A. Review of the Restraints-Seclusion (Medical and Behavioral) Policy, effective 01/10, revealed four raised side rails was considered a restraint and physician orders were required for all restraints.
B. Review of the Fall Event Report for a fall at 2100 on 09/16/10 revealed documentation that four side rails were raised after the patient was put back to bed.
B. Review of the nursing assessment documentation at 0700 and 1100 on 09/17/10 in the clinical record for Patient #10, revealed four side rails were up.
C. Review of the Physician's Orders for Patient #10, revealed a lack of an order to raise all four side rails.
D. The above was confirmed by the Regulatory Officer during interview at 1040 on 09/23/10.

Based on clinical record review, policy review, document review and interview, it was determined the facility failed to ensure one patient (#10) of one patient reviewed who had fallen while in the facility was evaluated by a Registered Nurse (RN) on admission related to morbid obesity equipment needs. The RN also failed to supervise nursing care related to following physician orders for suicide precautions and related to immediate notification of the physician after a fall. The failed practice had the potential to affect all obese patients, all patients on suicide precautions and all patients who fell while in the facility. Evidence follows:

A. Review of the Fall Event Report revealed the patient fell out of bed on 09/16/10 at 2100.

B. Review of the clinical record revealed a lack of evidence the physician was notified of the fall. The Adult Nursing Admission Record failed to address obesity and potential need for a bariatric bed. The patient was admitted to the facility from the Emergency Room. Admitting Physician Orders included suicide precautions.

C. Review of the Suicide Risk Assessment and Precautions (Outside of Behavioral Health Units) Policy, effective 10/09 revealed suicide precautions included continuous direct line of sight observation by a caregiver.

D. Review of the Fall Event Report completed by the Registered Nurse revealed the patient was found sitting on the floor and stated she fell out of bed. The Fall Event Report also documented the physician was not notified and the fall plan was incomplete, as the patient required a bariatric bed, but was on a regular bed.

E. Interview with the Nurse Manager of ICU and the CNO at 1045 on 09/23/10 revealed the facility had no bariatric beds and there was not an established policy for determining when a patient required a bariatric bed.

F. Interview with the Safety Officer at 0935 on 09/23/10 revealed patients admitted to the Emergency Room in need of a bariatric bed remained in ER and staff always stayed with the patient until the bariatric bed arrived.

G. The ICU Nurse Manager confirmed during interview at 0845 on 09/23/10 she had reviewed the fall report and the patient should have been on a bariatric bed and the physician should have been notified immediately following the fall. She confirmed she completed the Fall Root cause Analysis Report which documented staff did not witness the fall.