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Based on document review and interview, the hospital failed to ensure that nursing staff developed and kept current a nursing care plan that reflected the patient's goals and the nursing care to be provided to meet the patient's needs (P4, P7 and P8) (tag 396), and failed to ensure nursing staff adhered to Fall Risk policies and procedures (P&P) and/or patient treatment plans of the hospital for 7 of 10 patients (P1, P3, P4, P5, P7, P8 and P9) (tag 398).

The cumulative effect of these systemic problems resulted in the hospitals inability to ensure safe nursing care was provided.

Based on document review and interview, the hospital failed to ensure that nursing staff developed and kept current a nursing care plan that reflected the patient's goals and the nursing care to be provided to meet the patient's needs (P4, P7 and P8).

Findings include:

1. Review of the policy titled Fall Risk, Last Revised 1/2019, indicated the following:
RN (Registered Nurse):
1. Assesses patient's physical and mental condition to determine risk of falling...
2. Initiates Falls Protection Interventions as indicated by assessment and assigns risk level for geriatric and adult patients as follows: 0-99 Low Risk; 100+ High Risk. High Risk Interventions - Assessment Score of 100 or greater (not all inclusive): Problem addressed on Master Treatment Plan.
In the event a patient has a fall, or is found on the floor and a fall is suspected, the RN will (not all inclusive): Initiate or update a fall treatment plan.

2. Review of medical records (MR) indicated the hospital utilized the Edmonson Fall Risk Assessment as a tool to determine a patient's fall risk. The tool in the MRs indicated "Score 90 or > Obtain place on Fall Precautions"

A. The MR of patient P4 indicated the following: The Initial Nursing Assessment/Fall Risk Assessment (INA/FRA) scored the patient at 100. The MR lacked documentation of Fall Risk with precautions/interventions having been included in the patient's Individual Treatment Plan (ITP).

B. The MR of patient P7 indicated the following: The INA/FRA scored the patient at 95. Physician's order 6/25/21 indicated Fall Risk Precautions were ordered. The MR lacked documentation of a Fall Risk Treatment Plan.

C. The MR of patient P8 indicated the following: The INA/FRA scored the patient at 95. Physician's order 7/20/21 indicated Fall Risk Precautions were ordered. The MR lacked documentation of a Fall Risk Treatment Plan having been completed/implemented (the ITP Fall form was blank). Nursing Progress Notes (NPN) dated 7/20/21 at 0636 hours indicated the following: At approximately 0545 (hours) patient had unwitnessed fall in bedroom. Pt stated he/she "just fell". VS (vital signs)..., pt assessed and had small skin tear with contusion above left eyebrow. Large skin tear lateral to left eye at cheekbone/temporal area. Wounds cleaned, dressing applied... The MR lacked documentation of fall precautions implemented prior to or post fall.

3. Review of Fall incident reports indicated the following:
Patient P4: Date of incident: 6/7/21 - Patient was going to bathroom at 0630 hours, fell on right side. Bruises on right elbow.
Patient P7: Date of incident: 7/1/21 - Patient states he/she fell this morning. Bruise and small skin tear on left elbow.

4. On 8/31/21, beginning at approximately 4:15 PM, A1, Director of Regulatory Compliance, verified MR findings.

Based on document review and interview, the hospital failed to ensure nursing staff adhered to Fall Risk policies and procedures (P&P) and/or patient treatment plans of the hospital for 7 of 10 patients (P1, P3, P4, P5, P7, P8 and P9).

Findings include:

1. Review of the policy titled Fall Risk, Last Revised 1/2019, indicated the following:
RN (Registered Nurse):
1. Assesses patient's physical and mental condition to determine risk of falling...utilizing the Edmonson Fall Scale... If indicated, fall precautions is also documented on the patient's observation record.
2. Initiates Falls Protection Interventions as indicated by assessment and assigns risk level for geriatric and adult patients as follows: 0-99 Low Risk; 100+ High Risk.
Low Risk Interventions (not all inclusive): Reassess as needed.
High Risk Interventions - Assessment Score of 100 or greater (not all inclusive): Problem addressed on Master Treatment Plan. Bed and/or chair alarms. Assistive devices (e.g., canes, walkers) with non-skid tips. Q5 (every 5 minute) or 1:1 observation.
Reassess the patient daily to determine if the risk of falls has changed. If the risk has changed...the nurse will communicate the change to the physician. New orders for precautions or level of observation may change in addition to the above interventions.
In the event a patient has a fall, or is found on the floor and a fall is suspected, the RN will (not all inclusive): Adjust the precautions and/or observation level, if needed. Complete the post fall assessment and submit it to the DON (Director of Nursing) for review. Initiate or update a fall treatment plan.

2. Review of medical records (MR) indicated the hospital utilized the Edmonson Fall Risk Assessment as a tool to determine a patient's fall risk. The tool in the MRs indicated "Score 90 or > Obtain place on Fall Precautions"
A. The MR of patient P1 indicated the following: The initial nursing assessment (INA)/Edmonson Psychiatric Fall Risk Assessment (FRA) scored the patient at 103. The patient's Fall Risk Individual Treatment Plan included the following precautions to be implemented: Use of motion sensor alarms; Educate patient for toileting protocol and assist in regular toileting (1:1 with staff); Provide increased observation with 15 minute checks (the blank for minutes was filled in manually). Physician's orders 8/3/21 included Fall Risk precautions. Post Fall Assessment (PFA) documentation, 8/11/21 at 2215 hours, indicated the patient was standing in front of the nursing station...lost balance and fell to the floor. Update to the Treatment Plan (TP) lacked documentation of changes and/or new preventive fall precaution measures having been implemented. The MR indicated the patient fell again on 8/16/21. The Post Fall Assessment documentation at 1230 hours, Description of event indicated "Pt in dinning Rm" (Patient in dining room). Fall Interventions initiated after the event included "Staff assist when ambulating" and "First Aide". The PFA indicated the patient had a minor injury to his/her left index finger. Nursing Progress Notes (NPN) dated 8/16/21 at 1230 hours indicated the following: Pt (patient) sitting in "Geri" chair with alarm in place, pt stood up...and stumbled, falling into refrigerator. This nurse heard patient get up, pt had removed alarm. Pt fell a few feet from chair. Fall was unwitnessed. Pt found lying on left side with head touching refrigerator... The MR lacked documentation of the patient's alarm having sounded when he/she removed it and lacked documentation of the patient having been assessed every 5 minutes or on 1:1 with staff as per hospital policy for high fall risk (HFR) patients. The Close Observation Records for 8/11/21 and 8/16/21 indicated patient checks were done every 15 minutes (q15m), not Q5. Nursing documentation on 8/16/21 at 1320 hours indicated the following: Pt restless, unsteady gait, pt attempted to ambulate unassisted and fell at 1230 (hours). Update to the Treatment Plan (TP) indicated pt will demonstrate use of fall preventive measures including: Allow staff to assist - Treatment modality: 1:1 with staff; Immediately post fall and as needed. (See Fall/Incident reports and observation for additional information.)

B. The MR of patient P3 indicated the following: The INA/FRA scored the patient at 103. The patient's Fall Risk Individual Treatment Plan included the following precautions to be implemented: Use of motion sensor alarms; Educate patient for toileting protocol and assist in regular toileting (1:1 with staff); Provide increased observation with 15 minute checks (the blank for minutes was filled in manually); Mats on each side of the bed; Patient will use assistive device, as needed. Post Fall Assessment (PFA) documentation, 6/3/21 at 1030 hours, indicated the patient was found on floor of bathroom, floor was wet. Patient reported hitting head and his/her hip hurt. Fall interventions in place PRIOR to fall lacked documentation of bed/chair alarm or motion sensor in use. The form indicated the patient was admitted to an acute care hospital. NPN 6/3/21 at 1430 hours indicated the following: Pt was found on the floor in the bathroom... Fall was unobserved. Floor and shower curtain was (sic) wet...patient was nude... Pt reported hitting his/her head. This writer assessed pt and pt reported left shoulder pain and right knee pain initially, no hip pain upon palpation. Staff put draw sheet down and when attempting to roll him/her onto it, pt cried out in pain...this writer heard an audible "pop" sound. At this time it was decided to call EMS (Emergency Medical Services) and transfer to (acute care hospital)... The (acute care hospital) reported fracture of right hip. The Close Observation Record for 6/3/21 indicated patient checks were done every 15 minutes (q15m). The MR lacked documentation of a bed/chair alarm or motion sensor having been in place at the time of the fall and lacked documentation of the patient having been 1:1 for assistance at that time.

C. The MR of patient P4 indicated the following: The INA/FRA scored the patient at 100. The MR lacked documentation of Fall Risk with precautions/interventions having been included in the patient's Individual Treatment Plan (ITP); however, the Interdisciplinary Master Treatment Plan indicated Problem A, "Fall Risk". The MR lacked documentation of the patient having experienced a fall.

D. The MR of patient P5 indicated the following: The INA/FRA scored the patient at 93. The patient's Fall Risk Individual Treatment Plan included the following precautions to be implemented: Use of motion sensor alarms; Educate patient for toileting protocol and assist in regular toileting; Implement use of... mats on each side of the bed; Patient will use assistive device, as needed. Physician's orders 6/4/21 included Fall Risk precautions. PFA, 6/13/21 at 0920 hours, indicated staff heard bed alarm. Pt yelled out for help. Pt noted to be laying on floor next to his/her bed on right side. Physical Examination indicated the patient had redness to his/her right posterior arm. NPN 6/13/21 at 0930 indicated the Pt yelled out... Pt noted to be laying on the floor...next to his/her bed... The MR lacked documentation of mats present on each side of bed at time of the fall. Update to the Treatment Plan (TP), 6/13/21, included a short-term goal of "Pt. will demonstrate use of fall preventions measures including;" "Pt refuses to use walker, w/c (wheelchair), or staff assist". No other changes and/or new preventive fall precaution measures to be implemented were noted. The MR lacked documentation of the patient's fall risk having been reassessed. The MR indicated the patient fell again on 6/19/21. PFA note 6/19/21 at 0700 hours indicated the following: Pt lost his/her balance and fell into the column in D/R (Day room). The section titled "Fall Interventions initiated after the event" lacked documentation of new and/or different precautions having been implemented. TP update 6/19/21 included short-term goal of "Pt. will demonstrate use of fall preventions measures including;": Use of walker. The update lacked new and/or different implementation of precautions.

E. The MR of patient P7 indicated the following: The INA/FRA scored the patient at 95. Physician's order 6/25/21 indicated Fall Risk Precautions were ordered. The MR lacked documentation of a Fall Risk Treatment Plan. The MR lacked documentation of the patient having experienced a fall.

F. The MR of patient P8 indicated the following: The INA/FRA scored the patient at 95. Physician's order 7/20/21 indicated Fall Risk Precautions were ordered. The MR lacked documentation of a Fall Risk Treatment Plan having been completed/implemented (the ITP Fall form was blank). NPN dated 7/20/21 at 0636 hours indicated the following: At approximately 0545 (hours) patient had unwitnessed fall in bedroom. Pt stated he/she "just fell". VS (vital signs)..., pt assessed and had small skin tear with contusion above left eyebrow. Large skin tear lateral to left eye at cheekbone/temporal area. Wounds cleaned, dressing applied... The MR lacked documentation of a PFA form. The MR lacked documentation of fall precautions implemented prior to or post fall.

G. The MR of patient P9 indicated the following: The INA/FRA scored the patient at 111. The patient's Fall Risk Individual Treatment Plan included the following precautions to be implemented: Use of motion sensor alarms; Educate patient for toileting protocol and assist in regular toileting, 1:1 with staff; Implement use of... mats on each side of the bed; Patient will use assistive device, as needed. NPN 8/1/21 at 1900 hours indicated the following: Roommate came out of room and stated that patient had fallen. Pt noted to be laying beside his/her bed... ROM (range of motion) 100% to all extremities without complaint of pain. Abrasion noted to forehead. Assisted to standing position with difficulty... The MR lacked documentation of mats on each side of the bed and lacked documentation of alarm having sounded or been in place. The MR lacked documentation of a PFA form. Post Fall TP update, 8/1/21, lacked documentation of changes in protocol for fall precaution interventions by staff.

3. Review of Fall incident reports indicated the following:
Patient P4: Date of incident: 6/7/21 - Patient was going to bathroom at 0630 hours, fell on right side. Bruises on right elbow.
Patient P7: Date of incident: 7/1/21 - Patient states he/she fell this morning. Bruise and small skin tear on left elbow.

4. The following was indicated in interview on 8/31/21:
Beginning at approximately 1:45 PM, A1, Director of Regulatory Compliance, and A2, Chief Nursing Officer, indicated that nursing staff may increase frequency at which they perform a physician ordered or policy driven patient care task, such as observation frequency, but may not decrease the frequency without a provider order. They verbalized agreement that changing frequency of q5m (every 5 minute) checks, as per the Fall Risk policy, to q15m checks would require an order.

Beginning at approximately 3:00 PM, RN A3 indicated the facility did not have bed alarms and instead utilized motion sensors set on the floor in the middle of patient rooms as a fall precaution.

Beginning at approximately 4:15 PM, A1 verified MR findings.