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Based on record review and staff interview, the Hospital failed to ensure one of one Patient's was in a safe environment and that adequate provisions were implemented and documented to ensure the Patient's safety in September 2010.

The findings are as follow:

The Patient was admitted to the Hospital for the evaluation of lower gastrointestinal bleeding. Diagnoses consisted of myelogenous leukemia, anemia, myelodysplastic syndrome, thrombocytopenia and hypertension.

Review of the Nursing Admission Assessment dated 09/01/10 indicated the Patient was not initially identified as at risk for falls.

On 09/02/10, a Nurses Note at 7 AM indicated the Patient's bed alarm was activated for safety. There was no documented nursing assessment as to the change in the Patient's risk for falls. At 1:34 PM, the Nursing Assessment identified the Patient at high risk for falls with a score of 45 secondary to diagnosis and intravenous access. The Nursing Assessment indicated the Patient required frequent checks and the bed alarm on when family were not present. The rationale for the deactivation of the bed alarm intervention was not documented.

On 09/02/10 at 5:20 PM, the Patient was found on the floor kneeling with an arm outstretched to the end of the bed. The bed alarm had been turned off.

Registered Nurse #1 was interviewed in person on 10/26/10 at 11:25 AM. Registered Nurse #1 said the Patient was found on the floor, screaming in a kneeling position and holding onto the foot of the bed. Registered Nurse #1 said the Patient had been up to the commode and urinated. Registered Nurse #1 said the Patient denied striking the head. However, the Patient was non-English speaking and required an appropriate interpreter.

Registered Nurse #1 said Hospitalist #1 was informed the Patient fell. Hospitalist #1 did not evaluate the Patient. Registered Nurse #1 said the Patient's family arrived to the unit approximately one hour following the Patient's fall. Registered Nurse #1 said the Patient's family reported the Patient was complaining of a headache and later retracted the statement. Registered Nurse #1 said the family reported the Patient was confused which was a change in the Patient's mental status.

Review of the Progress Note for Hospitalist #2 dated 09/02/10 at 9:45 PM indicated Hospitalist #2 was called for a change in mental status at 7:50 PM. Two hours after the Patient's fall and one hour twenty minutes after the family's arrival to the unit. Hospitalist #2 ordered a head computerized tomography (CT)scan for the Patient which indicated the Patient had a new small subdural hematoma.

Continued review of the medical record indicated arrangements were made for the Patient's transfer to a trauma center.

The Patient was transferred by ambulance between 11:30 PM on 09/02/10 and 12 AM on 09/03/10, however the specific time was not documented.

Review of a late entry Nurse Note dated 09/03/10 at 12:53 AM indicated the Patient had no redness on the head or shoulder. Registered Nurse #1 indicated the Patient seemed to motion to the left shoulder and seemed to deny any discomfort. It was not clear as to what the nursing entry meant. Registered Nurse #1 indicated the Patient's family requested the Patient be administered medication to help the Patient sleep. Registered Nurse #1 administered medication Ativan. There was no evidence Registered Nurse #1 discussed administering the Ativan to the Patient with Hospitalist #2.

There were no documentation of a nursing neurological assessment by Registered Nurse #1. There was no documentation of reassessment of the Patient by Registered Nurse # 1after a report of a change in the Patient's mental status described by the Patient's family an hour after the fall..

Registered Nurse #1 failed to recognize the Patient's mental status changes and report the changes to a physician in a timely manner.

Based on record review, physician and staff interview, the nursing staff failed to adequately monitor and assess one of one Patient's for injures after a fall in September 2010.

The findings are as follow:

The Patient was admitted to the Hospital for the evaluation of lower gastrointestinal bleeding. Diagnoses consisted of myelogenous leukemia, anemia, myelodysplastic syndrome, thrombocytopenia and hypertension.

Review of the Nursing Admission Assessment indicated the Patient was not initially identified as at risk for falls.

On 09/02/10, a Nurses Note at 7 AM indicated the Patient's bed alarm was activated for safety. There was no documented nursing assessment as to the change in the Patient's risk for falls. At 1:34 PM, the Nursing Assessment identified the Patient at high risk for falls with a score of 45 secondary to diagnosis and intravenous access. The Nursing Assessment indicated the Patient required frequent checks and the bed alarm on when family were not present. The rationale for the deactivation of the bed alarm intervention was not documented.

On 09/02/10 at 5:20 PM, the Patient was found on the floor kneeling with an arm outstretched to the end of the bed. The bed alarm had been turned off.

Registered Nurse #1 was interviewed in person on 10/26/10 at 11:25 AM. Registered Nurse #1 said the Patient was found on the floor, screaming in a kneeling position and holding onto the foot of the bed. Registered Nurse #1 said the Patient had been up to the commode and urinated. Registered Nurse #1 said the Patient denied striking the head. However, the Patient was non-English speaking and required an appropriate interpreter. Registered Nurse #1 said Hospitalist #1 was informed the Patient fell. Hospitalist #1 did not evaluate the Patient. Registered Nurse #1 said the Patient's family arrived to the unit approximately one hour following the Patient's fall. Registered Nurse #1 said the Patient's family reported the Patient was complaining of a headache and later retracted the statement. Registered Nurse #1 said the family reported the Patient was confused which was a change in the Patient's mental status.

Review of the Progress Note for Hospitalist #2 dated 09/02/10 at 9:45 PM indicated Hospitalist #2 was called for a change in mental status at 7:50 PM. Two hours after the Patient's fall and one hour twenty minutes after the family's arrival to the unit. Hospitalist #2 ordered a head computerized tomography (CT)scan for the Patient which indicated the Patient had a new small subdural hematoma.

Continued review of the medical record indicated arrangements were made for the Patient's transfer to a trauma center.

The Patient was transferred by ambulance between 11:30 PM on 09/02/10 and 12 AM on 09/03/10, however the specific time was not documented.

Review of a late entry Nurse Note dated 09/03/10 at 12:53 AM indicated the Patient had no redness on the head or shoulder. Registered Nurse #1 indicated the Patient seemed to motion to the left shoulder and seemed to deny any discomfort. It was not clear as to what the nursing entry meant. Registered Nurse #1 indicated the Patient's family requested the Patient be administered medication to help the Patient sleep. Registered Nurse #1 administered medication Ativan. There was no evidence Registered Nurse #1 discussed administering the Ativan to the Patient with Hospitalist #2.

There were no documentation of a nursing neurological assessment by Registered Nurse #1. There was no documentation of reassessment of the Patient by Registered Nurse # 1 after a report of a change in the Patient's mental status described by the Patient's family an hour after the fall..

Registered Nurse #1 failed to recognize the Patient's mental status changes and report the changes to a physician in a timely manner.