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The Condition is not met as evidenced by the facility failed to ensure the Condition of Participation: CFR 482.13 Patient Rights was met by failing to implement the facility's policy and procedure (P&P) for Patient 1, who was at high risk for bleeding and falls, received care in a safe setting when:

a. Registered Nurse 3 (RN 3) did not verify Patient 1's bed alarm (sounds to alert staff when patients attempt to get out of bed unassisted) was turned on.

b. RN 3 did not give Hand-Off communication (bedside endorsement) to RN 1.

On 1/12/21 at 4:50 PM, Patient 1 was found in his room sitting on the floor (unwitnessed fall) by RN 1. These failures may have contributed to Patient 1's death on 1/12/21 at 11:45 PM (seven hours after being found on the floor).

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Patient Rights.

Based on interview and record review, the facility failed to implement their policy and procedure (P&P) for Patient 1, who was at high risk for bleeding and falls, received care in a safe setting when:

a. Registered Nurse 3 (RN 3) did not verify Patient 1's bed alarm (sounds to alert staff when patients attempt to get out of bed unassisted) was turned on.

b. RN 3 did not give Hand-Off communication (bedside endorsement) to RN 1.

On 1/12/21 at 4:50 PM, Patient 1 was found in his room sitting on the floor (unwitnessed fall) by RN 1. These failures may have contributed to Patient 1's death on 1/12/21 at 11:45 PM (seven hours after being found on the floor).

Findings:

During a review of Patient 1's Face Sheet, the Face Sheet indicated, Patient 1 was admitted to the facility on 12/26/20, with diagnoses that included Leukemia (cancer of the blood; people may experience fatigue, bleeding, easy bruising, dizziness, and weakness).

During a review of Patient 1's Laboratory results, dated 1/12/21 at 7 AM, the Laboratory results indicated, Patient 1's platelet (tiny fragments of blood cells that are essential for normal blood clotting) level was 6,000 per microliter [mcl] of blood. This result was critically low- having less than 150,000 is known as thrombocytopenia [place a person at risk for severe bleeding].

During a review of Patient 1's Hester Davis Scale Fall Risk flowsheet (a fall risk assessment tool that indicates a score 15 or greater means high risk for falls), dated 1/12/21 at 8 AM, the Fall Risk flowsheet indicated, Patient 1's fall risk score was 18. Patient 1's plan of care interventions included to educate patient on the utilization of the bed alarm was incomplete. Patient was alert and oriented to date, place, and person.

During a review of the facility's P&P, titled, "Fall Precautions Care of the Patient at Risk for Falling," dated 8/19, the P&P indicated, "On admission, every shift, and whenever there is a significant change in the patient's condition, the nurse will assess and document the patient's risk for falls using Hester Davis (for adult inpatient areas). A Hester Davis score of 7 or greater indicates potential falls risk and requires the implementation of generals as well as patient specific fall prevention measures: The Yellow Fall Prevention Kit and Bed Alarms ..."

During a concurrent interview and record review with RN 3, on 1/20/21 at 12:05 PM, RN 3 verified there was no documented evidence to indicate Patient 1's bed alarm was turned on prior to the patient being found on the floor on 1/12/21 at 4:50 PM.

During a review of Patient 1's Nursing Narrative Note, documented by RN 1, dated 1/12/21 at 5:25 PM, the Nursing Narrative Note indicated, Patient 1 was found sitting next to his bed on the floor wet with urine, at 4:50 PM. Patient 1 was unable to state what happened. Patient 1 had difficulty finding words. Patient 1 noted to have right flank (waist area) bruise.

During an interview on 1/21/21 at 9:30 AM, with RN 1, RN 1 stated RN 3 did not give her Hand-off Communication (bedside endorsement) regarding Patient 1 prior to her assuming care, on 1/12/21 at 4:50 PM. RN 1 stated she found Patient 1 sitting on the floor near the right side of the bed on 1/12/21 at 4:50 PM. RN 1 stated Patient 1 had a right flank bruise.

During an interview on 1/20/21 at 2:27 PM, with RN 3, RN 3 stated Patient 1 was asleep in bed on 1/12/21 at 4:35 PM. RN 3 stated he did not verify Patient 1's bed alarm was turned on at that time. RN 3 also stated he did not give Hand-off Communication (bedside report) to RN 1 on 1/12/21, when RN 1 assumed Patient 1's care.

During a review of Patient 1's Physician Note, documented by Medical Doctor (MD 2), dated 1/12/21 at 7:25 PM, the Physician Note indicated, Patient 1 was found on the floor and unknown how he fell. Within the next hour after the fall, Patient 1 became unresponsive and found to have a large area of bleeding in his brain.

During a review of Patient 1's Head Computed Tomography (CT- a three dimensional image of an internal body structure) scan results, dated 1/13/21 at 7:39 AM, the results indicated, suspicious for intraparenchymal hemorrhage (bleeding within the brain).

During an interview on 1/21/21 at 3 PM, with MD 2, MD 2 stated Patient 1's platelets was low on 1/12/21 at 7 AM, and he was on bleeding precautions. MD 2 stated that after the fall Patient 1 had a tiny bump located at the right side of his forehead.

During a review of Patient 1's Nursing Narrative Note, documented by RN 2, dated 1/12/21 at 8 PM, the Nursing Narrative Note indicated, Patient 1 was unresponsive, pupils fixed and dilated, gasping for air and had labored breathing (abnormal breathing).

During an interview on 1/21/21 at 10:55 AM, with MD 1, MD 1 stated Patient 1's fall, on 1/12/21, could have contributed to Patient 1's intracranial bleed (bleeding within the brain).

During a review of Patient 1's Death Note, documented by MD 1, dated 1/12/21, the note indicated, Patient 1 was found to not have a pulse, no heart sounds, no spontaneous respiration, unresponsive to stimuli, fixed and dilated pupils. Patient 1 was pronounced dead on 1/12/21 at 11:45 PM (seven hours after being found on the floor by RN 1).

During an interview on 1/21/21 at 1:41 PM, with the Chief Nursing Executive (CNE), the CNE stated the nursing staff should have followed the facility's policy and procedure for endorsement of patient care from one nurse to another.

During a review of the facility's P&P, titled, "Endorsement of Patient Care from One Nurse to Another: Hand-off Communication; Nurse Knowledge Exchange Plus," dated 8/19, the P&P indicated, "Nurse knowledge exchange will be done anytime a patient's care is being transferred from one caregiver to another, including at shift change, when physically transferring the patient between departments, level of care, or facilities, or when turning care over to another specialty service or care or caregiver. Hand-off communication will be performed at the patient's bedside with patient. Hand-off communications will include the patient's name, diagnosis, recent clinical changes, and problem list. Hand-off communications will allow for questions and validation of clinical information and two-way dialogue. Validation of information will be achieved by utilizing the electronic medical record, as well as, the contents of the hard copy medical record, as needed. Hand off communication will include a safety check to include: High alert medications, equipment, alarms, lines, and skin ..."