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Based on observation, record review and interview the facility failed to ensure that nursing care was supervised by the Registered Nurse. The Registered Nurse failed to assess the specific care needs of 1 of 6 Sample Patients (SP) sample patient #1 and provide interventions based on the patients' specific health status that contributed to the fall of SP#1.

The findings include:

Interview conducted on 2-24-2011 at 1:40PM with SP#1, revealed that on 2-8-2011 at about 4:30AM the patient was in bed when Staff #1 came in to his room to check on him. SP#1 stated that the nurse left his room stating that she needed to obtain some supplies; the nurse never returned. SP#1 stated that due to the nature of his illness, he had a sudden urgency to get to the toilet due to multiple loose bowel movements each day. When on the toilet, he stated he activated the call light for assistance because he felt dizzy.

Clinical record review of conducted on 2-24-2011 of SP#1, revealed that the patient was hospitalized on 1-11-2011 with an admitting diagnosis on Urinary Tract Infection, Septic Shock and Renal Insufficiency and was also diagnosed with Diverticulitis that required intravenous (IV) antibiotics for 28 days. The record further indicated that SP#1 had a Deep Vein Thrombosis and was receiving continuous IV anticoagulant therapy (Heparin) and had a Foley (urinary) catheter in place. The Morse fall risk assessment completed on 2-7-2011 for the 7AM-7PM and the 7PM-7AM shifts indicate that SP#1 received a score of 45 for both shifts. The fall assessment indicated a check off box to Initiate Fall Prevention measures for an at risk score above 25. The nurses note from Staff #3 dated 2-8-2011 at 5:45AM indicated that SP#1 had a fall with injury to his head with Certified Nursing Assistant (CNA) present. SP#1 was assessed by the Physician and had diagnostic scans ordered.

Record review of Policy and Procedures relating to Falls Prevention indicates that the facility has a system in place to identify and assess patients that are at risk for falls. The policy further indicates that an incident report will be completed post fall in order to identify the causes contributing to the fall.

Record review of the Hospitals incident report log for February 2011 on 2-24-2011 at 2:15PM, failed to show that a report was made regarding the fall of SP#1.

Interview with the Risk Manager and Compliance Officer on 2-24-2011 at 2:55PM confirmed no incident report made and no investigation determining the contributing factors of the fall was completed.

Interview with Staff #1 via telephone, on 2-24-2011 at 5:28PM revealed that she was walking in the corridor near the nurse station when she noticed the emergency call light on for Room 406. She further stated that she saw Staff #2 and Staff #3 in the nurse station sitting and documenting; and called to their attention the emergency light. Upon entering the room of SP#1, Staff #1 realized that he was not in bed but sitting on the toilet. She explained to SP#1 that he needed to call for assistance when he needs to get up to the bathroom at which point he appeared dizzy and confused and began to lean to the side. Staff #1 assisted SP#1 to the floor but he struck his head on the wall. Staff #1 stated that other staff responded and lifted SP#1 and put him in bed.

Interview with Staff #2 revealed that she had poor recollection of any incident taking place and stated that she did recall going in to the room of SP#1 with the Physician and escorting him to his scans. When questioned about fall precautions in place, Staff #2 stated that she rounds on every patient to assure that safety measures are being followed and explained in detail the types of measures used for fall precautions.

Interview with Staff# 3 via telephone, on 2-24-2011 at 6:20PM revealed that she was the nurse assigned to SP#1 when he fell in the bathroom. She stated that she responded to the room and assisted SP#1 back to bed with other staff. She stated that she had been in the room about 15 minutes earlier and offered SP#1 to use the bathroom but he was not ready yet. Staff # 3 further stated that SP#1 was awake and oriented to person place and time and advised SP#1 to use the call light when he is ready to go to the bathroom. Staff # 3 stated she left the room to obtain supplies of an unknown nature and did not return to the room until after the fall. Staff# 3 stated that she was aware that SP#1 was a fall risk and had the fall prevention measures implemented at the time of the fall. Staff #3 stated that she failed to make an incident report because of computer problems.

Based on observation, record review and interview the facility failed to ensure that nursing care was supervised by the Registered Nurse. The Registered Nurse failed to assess the specific care needs of 1 of 6 Sample Patients (SP) sample patient #1 and provide interventions based on the patients' specific health status that contributed to the fall of SP#1.

The findings include:

Interview conducted on 2-24-2011 at 1:40PM with SP#1, revealed that on 2-8-2011 at about 4:30AM the patient was in bed when Staff #1 came in to his room to check on him. SP#1 stated that the nurse left his room stating that she needed to obtain some supplies; the nurse never returned. SP#1 stated that due to the nature of his illness, he had a sudden urgency to get to the toilet due to multiple loose bowel movements each day. When on the toilet, he stated he activated the call light for assistance because he felt dizzy.

Clinical record review of conducted on 2-24-2011 of SP#1, revealed that the patient was hospitalized on 1-11-2011 with an admitting diagnosis on Urinary Tract Infection, Septic Shock and Renal Insufficiency and was also diagnosed with Diverticulitis that required intravenous (IV) antibiotics for 28 days. The record further indicated that SP#1 had a Deep Vein Thrombosis and was receiving continuous IV anticoagulant therapy (Heparin) and had a Foley (urinary) catheter in place. The Morse fall risk assessment completed on 2-7-2011 for the 7AM-7PM and the 7PM-7AM shifts indicate that SP#1 received a score of 45 for both shifts. The fall assessment indicated a check off box to Initiate Fall Prevention measures for an at risk score above 25. The nurses note from Staff #3 dated 2-8-2011 at 5:45AM indicated that SP#1 had a fall with injury to his head with Certified Nursing Assistant (CNA) present. SP#1 was assessed by the Physician and had diagnostic scans ordered.

Record review of Policy and Procedures relating to Falls Prevention indicates that the facility has a system in place to identify and assess patients that are at risk for falls. The policy further indicates that an incident report will be completed post fall in order to identify the causes contributing to the fall.

Record review of the Hospitals incident report log for February 2011 on 2-24-2011 at 2:15PM, failed to show that a report was made regarding the fall of SP#1.

Interview with the Risk Manager and Compliance Officer on 2-24-2011 at 2:55PM confirmed no incident report made and no investigation determining the contributing factors of the fall was completed.

Interview with Staff #1 via telephone, on 2-24-2011 at 5:28PM revealed that she was walking in the corridor near the nurse station when she noticed the emergency call light on for Room 406. She further stated that she saw Staff #2 and Staff #3 in the nurse station sitting and documenting; and called to their attention the emergency light. Upon entering the room of SP#1, Staff #1 realized that he was not in bed but sitting on the toilet. She explained to SP#1 that he needed to call for assistance when he needs to get up to the bathroom at which point he appeared dizzy and confused and began to lean to the side. Staff #1 assisted SP#1 to the floor but he struck his head on the wall. Staff #1 stated that other staff responded and lifted SP#1 and put him in bed.

Interview with Staff #2 revealed that she had poor recollection of any incident taking place and stated that she did recall going in to the room of SP#1 with the Physician and escorting him to his scans. When questioned about fall precautions in place, Staff #2 stated that she rounds on every patient to assure that safety measures are being followed and explained in detail the types of measures used for fall precautions.

Interview with Staff# 3 via telephone, on 2-24-2011 at 6:20PM revealed that she was the nurse assigned to SP#1 when he fell in the bathroom. She stated that she responded to the room and assisted SP#1 back to bed with other staff. She stated that she had been in the room about 15 minutes earlier and offered SP#1 to use the bathroom but he was not ready yet. Staff # 3 further stated that SP#1 was awake and oriented to person place and time and advised SP#1 to use the call light when he is ready to go to the bathroom. Staff # 3 stated she left the room to obtain supplies of an unknown nature and did not return to the room until after the fall. Staff# 3 stated that she was aware that SP#1 was a fall risk and had the fall prevention measures implemented at the time of the fall. Staff #3 stated that she failed to make an incident report because of computer problems.