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Based on interview, medical record review, observation and policy review, the facility failed to evaluate patients with high risk for falls (A395) and failed to ensure the nursing staff develops, and keeps current, a nursing care plan for each patient (A396). The cumulative effect of these systemic practices resulted in the facility's inability to ensure that all patients at high risk for falls would be identified and have safety precautions implemented to prevent falls. The facility census was 137 patients with 19 of these patients identified as being high risk for falls during the time of the survey.

Based on medical record review, policy review and interview, the facility failed to identify pertinent diagnoses when assessing fall risks for two patients reviewed (Patient #2 and #13) in accordance with the facility's policy. This had the potential to affect all 137 active patients.


Findings include:


1. Patient #2 was admitted to the facility on 07/07/15 with a diagnosis of cellulitis. Patient #2's history and physical note listed the diagnoses as seizure disorder and morbid obesity. A physician progress note from 07/10/15 at 1:49 PM listed Patient #2 as having blindness of the left eye.

Review of a nursing admission assessment on 07/07/15 at 10:59 PM, a nurse documented Patient #2 as having a fall risk score of 30 (medium risk for falls). The Admission Fall Risk Assessment stated Patient #2 did not have any pertinent diagnosis related to fall risk.

According to the facility's Fall Prevention Guidelines policy, a patient would be scored an additional five points if the patient had any pertinent diagnosis. On 07/08/15 at 2:00 AM and 4:26 AM, a nurse documented Patient #2 as having a fall risk score of 30 and as having no pertinent diagnosis.

Patient #2 fell at the facility on 07/10/15 around 9:52 AM and on 07/14/15 at 11:45 AM. After the fall on 07/10/15, Patient #2 was assessed on 07/10/15 at 9:57 AM as being a high risk for falls with a fall score of 35.


2. Patient #13 was admitted to the facility from 07/04/15 through 07/06/15 with a diagnosis including chronic obstructive pulmonary disease and peripheral neuropathy. On the history and physical completed on 07/05/15, a physician documented Patient #13 has a history of neuropathy which makes it very difficult to walk. Patient #3 was assessed as being a medium risk for falls from 07/05/15 through 07/06/15. Patient #13 fell at the facility at 2:35 AM on 07/06/15. On 07/06/15 at 8:00 AM, a nurse assessed Patient #13 as being a medium risk for falls. The nurse documented Patient #13 did not have any pertinent diagnosis related to falls. The medical record review for Patient #13 revealed Patient #13 was seen at the facility emergency department on 07/03/15 for continued pain following a fall six days prior.

3. The facility's Fall Prevention Guidelines policy (Number: B:70) was reviewed. The policy stated nursing interventions will be implemented based on patients' fall risk status. A score of 35 to 60 indicates a high risk for a fall. A sticker will be placed on the front of the chart so that ancillary departments are aware. Place a red blanket and red safety socks on the patient.

Based on medical record review, observations, policy review and interview, the facility failed to ensure nursing care plans were completed and nursing interventions were implemented in accordance with the facility's policy for nine patients (Patient #2, #3, #4, #5, #8, #9, #11, #12 and #13) of 13 medical records reviewed and for seven of ten patients identified as being high risk for falls observed in rooms 407-1, 407-2, 454.1, 359, 365, 221-1 and 275-1. This had the potential to affect all 137 active patients and 19 patients identified as high risk for falls patients.


Findings include:


1. The facility's Fall Prevention Guidelines policy (Number: B:70) was reviewed. The policy stated nursing interventions will be implemented based on patients' fall risk status. A score of 35 - 60 indicates a high risk for a fall. A sticker will be placed on the front of the chart so that ancillary departments are aware. Place a red blanket and red safety socks on the patient.

2. Tour of nursing units on 03/21/16 from 2:15 PM to 3:00 PM revealed patients that were assessed to be at high risk for falls, located in rooms 407-1, 407-2, 454.1, 359, 365, 221-1 and 275-1, were not observed to have had interventions of red socks or red blankets per facility policy. Review of medical records for the following rooms of high risk fall patients: 404-2, 407-1, 407-2, 454-1, 462-1, 468-1, 471.1, 359, 365, 362, 221-1, and 275-1 were not observed to have high risk sticker on the front of the medical record per facility policy.
Interview with Staff A and Staff C on 03/21/16 at the time of the tour confirmed the above findings.

3. The medical record review for Patient #2 revealed Patient #2 was admitted to the facility on 07/07/15 with a diagnosis including seizure disorder. The nursing care plan for Patient #2 was reviewed and listed problems of impaired mobility, impaired skin integrity, knowledge deficit and pain. The care plan did not include seizures. A physician ordered seizure precautions for Patient #2 on 07/07/15 at 6:47 PM. The medical record did not contain evidence of nursing staff implementing seizure precautions.

The findings were shared with Staff C on 03/22/16 at 2:05 PM and confirmed.

Patient #2 was assessed as being at high risk for falls on 07/10/15. The medical record did not contain documentation of Patient #2 having red safety socks or a red blanket, in accordance with the facility's policy for patients who are at high risk for falls.

The findings were shared with Staff B on 03/22/15 at 8:00 AM and confirmed.


4. Patient #3 was admitted to the facility from 07/02/15 through 07/04/15 with a diagnosis including cellulitis. Patient #3 was assessed as being a high risk for falls on 07/03/15 and 07/04/15. The medical record did not contain documentation of Patient #3 having red safety socks or a red blanket, in accordance with the facility's policy for patients who are at high risk for falls.

The findings were shared with Staff B on 03/22/15 at 8:00 AM and confirmed.

5. Patient #4 was admitted to the facility from 07/10/15 through 07/12/15 with a diagnosis including cellulitis. Patient #4 was assessed as being a high risk for falls on 07/11/15. The medical record did not contain documentation of Patient #4 having red safety socks or a red blanket, in accordance with the facility's policy for patients who are at high risk for falls.

The findings were shared with Staff B on 03/22/15 at 8:00 AM and confirmed.

6. Patient #11 was admitted to the facility from 07/11/15 through 07/16/15 with a diagnosis including Syncopal episodes. Patient #11 was assessed as being a high risk for falls on 07/16/15 at 2:00 AM. The medical record did not contain documentation of Patient #11 having red safety socks or a red blanket, in accordance with the facility's policy for patients who are at high risk for falls. Patient #11 fell at the facility on 07/16/15 at 10:57 AM.

The findings were shared with Staff B on 03/22/16 at 8:00 AM and confirmed.

7. Patient #12 was admitted to the facility on 07/01/15 with a diagnosis including obesity and diabetic neuropathy. Patient #12 was assessed as being a high risk for falls at 4:00 AM on 07/05/15 and at 4:00 AM on 07/06/15. The medical record did not contain documentation of Patient #12 having red safety socks or a red blanket, in accordance with the facility's policy for patients who are at high risk for falls. Patient #12 fell at the facility on 07/06/15 at 9:30 AM. On 07/06/15 at 9:30 AM, Patient #12 was assessed as being high risk for falls and a nurse did not document Patient #12 having red safety socks or a red blanket.

The findings were shared with Staff B on 03/22/16 at 8:00 AM and confirmed.

8. Patient #13 was admitted to the facility from 07/04/15 through 07/06/15 with a diagnosis including chronic obstructive pulmonary disease and peripheral neuropathy. On the history and physical completed on 07/05/15, a physician documented Patient #13 has a history of neuropathy which makes it very difficult to walk. Patient #3 was assessed as being a medium risk for falls from 07/05/15 through 07/06/15. Patient #13 fell at the facility at 2:35 AM on 07/06/15. On 07/06/15 at 8:00 AM, a nurse assessed Patient #13 as being a medium risk for falls. The nurse documented Patient #13 did not have any pertinent diagnosis related to falls. The medical record review for Patient #13 revealed Patient #13 was seen at the facility emergency department on 07/03/15 for continued pain following a fall six days prior.

The findings were shared with Staff B on 03/22/16 at 8:00 AM and confirmed.

9. Review of Patient #5's medical record on 03/22/16 revealed the patient was admitted to the facility on 03/17/16 with diagnosis including; urinary tract infection, sepsis, accidental fall, and muscle weakness. Review of Patient #5's fall risk assessments dated 03/17/16, revealed the patients risk score was noted to be 40 with the high fall risk level range of 35-60. Review of the patient safety measures revealed the bed was in low position, brake set, call light within reach, and side rails up times two. The medical record revealed no documented evidence the facility staff had given the patient red slippers or a red blanket per the facility policy for high risk fall patients.
Interview with Staff C on 03/22/16 at 7:37 AM confirmed patient #5 was considered a high risk fall patients with no evidence the interventions of red slippers or a red blanket was put in place.

10. Review of Patient #8's medical record on 03/22/16 revealed the patient was admitted to the facility on 03/14/16 with diagnosis including: syncope and collapse, ambulatory dysfunction, paresthesia, and numbness. Review of Patient #8's fall risk assessments dated 03/15/16, revealed the patients risk score was noted to be 35 to 40 with the high fall risk level range of 35-60. Review of the patient safety measures revealed the bed was in low position, brake set, call light within reach, and side rails up times two. The medical record revealed no documented evidence the facility staff had given the patient red slippers or a red blanket per the facility policy for high risk fall patients.
Interview with Staff C on 03/22/16 at 8:30 AM confirmed patient #8 was considered a high risk fall patients with no evidence the interventions of red slippers or a red blanket was put in place.

11. Review of Patient #9's medical record on 03/22/16 revealed the patient was admitted to the facility on 03/14/16 with diagnosis including: malignant neoplasm of lung, and anxiety. Review of Patient #9's fall risk assessments dated 03/20/16 and 03/21/16 revealed the patients risk score was noted to be 35 to 40 with the high fall risk level range at 35-60. Review of the patient safety measures revealed the bed was in low position, brake set, call light within reach, and side rails up times three and four. The medical record revealed no documented evidence the facility staff had given the patient red slippers or a red blanket per the facility policy for high risk fall patients.
Interview with Staff C on 03/22/16 at 9:00 AM confirmed patient #9 was considered a high risk fall patients with no evidence the interventions of red slippers or a red blanket was put in place.

12. The facility's Plan of Care policy (Number E:29) was reviewed and stated an individualized care plan will be utilized on each nursing unit. The care plan is based on patient needs identified by a registered nurse during patient assessment. The care plan will be modified to meet the patient's changing needs.