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Based on facility policy review, medical record review, and staff interview, the nursing staff failed to supervise and evaluate patient care by failing to implement post fall management for an unwitnessed patient fall in 1 of 3 high risk falls patients sampled (Patient #3).

The findings included:

Review of the facility policy, Fall Prevention Program, revised 07/2018, revealed, "Post Fall Management (Adults and Pediatrics) A. Immediate nursing care includes: ... – Assessment of Vital Signs and Neuro status per post-fall assessment guidelines. (Exhibit C) ... B. Complete Post-Fall flowsheet in EHR ... Exhibit C Post-Fall Assessment ... Hits head or has unwitnessed fall ... Proceed to: -Record neurologic observations, including Glasgow Coma Scale. Observe for signs indicating stroke, change in consciousness, headache, amnesia (memory loss), or vomiting ... - Review current care plan and implement additional fall prevention strategies – Observations: - Record vital signs and neurologic observations at least hourly for 4 hours and then review ..."

Closed medical record review of Patient #3 revealed a 66-year-old male was admitted to the facility on 11/28/2020 at 0304 with chief complaints of trauma – fall. Review of the History & Physical dated 11/28/2020 0625 revealed, "HPI (History of Present Illness): (named Patient #3)... presents as a Level 2 trauma activation after sustaining injuries in a fall earlier this evening ... When the patient arrived, he was GCS 14(Glasgow Coma Scale – scale used to assess level of consciousness; scores range from 3 (lowest) to 15 (highest level of consciousness)), ABC (Airway, Breathing, Circulation) intact, and hemodynamically(blood flow in circulation) stable ... Impression: ...Found to have the following injuries: - L (left) SDH (subdural hematoma- bleeding underneath the dural membrane(connective tissue that surrounds the brain and spinal cord)) 10 mm (millimeter) with midline shift – SDH/SAH (subarachnoid hemorrhage - bleeding within the subarachnoid space(space between the brain and skill that contains cerebrospinal fluid)) in frontal R (right) convexity(curvature of the front of the brain) – Occipital bone fracture. Recommendations: Patient to go to OR (operating room) ..." Medical Record Review revealed Patient #3 was transferred from an intensive care unit to a neurology unit on 12/04/2020 at 2111. Review of the Nursing Notes dated 12/04/2020 at 2344 revealed, "Per CNA (Certified Nurse Assistant) (named CNA #2) Bed alarm went off and she ran to patient ' s room, she heard a loud thud and found patient kneeling on the floor and in the process of trying to climb back in the bed ... MD paged. Dr. (named MD #3) at the bedside. After he (MD #3) did a thorough assessment on patient..." Review of Nursing Assessment dated 12/05/2020 at 0431, "Neurological GCS Score – 14" (5 hours after the fall). Medical record review revealed Patient #3 expired on 12/15/2020 at 1300 at the facility. Review of the Plan of Care failed to reveal updates from 12/04/2021 (date of the unwitnessed fall) through 12/06/2021. Medical record review failed to reveal: documentation of a nursing assessment after Patient #3 ' s unwitnessed fall, nursing documentation on the Post-Fall flowsheet, neurological assessments hourly for four hours post fall, and updates to the care plan that reflected the implementation of additional fall prevention strategies.

Interview on 07/28/2021 at 1615 with RN #1 revealed they assumed nursing care for Patient #3 on the night of 12/04/2020. Interview revealed Patient #3 had an unwitnessed fall at approximately 2300. Interview revealed 12/04/2020 was a "busy night" and that RN #1 completed a nursing note and event report system note. Interview revealed the post fall management policy was not implemented in its entirety.

Interview on 07/29/2021 at 0845 with CNA #2 revealed they found Patient #3 after his unwitnessed fall on the night of 12/04/2020. Interview revealed documentation of the fall and assessments were deferred to the primary nurse caring for the patient.

Interview on 07/29/2021 at 1005 with NM (Nurse Manager) #4 revealed the expectation was that nursing staff documented their assessments of patients after a change in condition or an event. Interview revealed the RN should have documented their post fall assessment findings in the EHR and Event Reporting system. Interview revealed the RN should have monitored the patient ' s neurological changes closely, "no matter how little."

Based on facility policy review, medical record review, and staff interview, the facility staff failed to maintain documentation of physician and nursing assessments necessary to monitor a patient ' s condition for 1 of 1 patient reviewed with an unwitnessed fall (Patient #3).

The findings included:

Review of the facility policy, Medical Record Completion, revised 04/2019, revealed, "...a) Scope: ... attending physicians, residents, fellows .... 3) Policy Guidelines A. Completion Requirements ... Some specific documents within the medical record require more stringent timelines and shall be completed within the specified timelines as required by Medical Staff Rules and Regulations and/or regulatory agency ... Progress Notes – Completed and signed by reporting provider – Recorded at the time of observation or immediately after visit ..."

Review of the facility policy, Documentation of Patient Care, revised 05/2017, revealed, "Scope: Registered Nurses, and health care providers supervised by a Registered Nurse (RN) who document provision of direct care in the electronic health record (EHR) ... 3) Procedure: A. Documentation of patient care supports the nursing process as reflected in the EHR. The information documented reflects nursing assessments, care provided to the patient, and the patient response/outcome to that care ... C. Documentation Frequency: ...2. Flowsheet Reassessment Frequencies: a. When a significant change in condition or event occurs ... 3. Care Plan and Patient Education: ...b. Updated at least every 24 hours c. Updated when change in the patient ' s condition ... Individual Responsibilities for Documentation of Patient Care ... The RN is responsible for completion of all sections of the Nursing Assessment, Nursing Care, and Ongoing Assessment as applicable to the patient .... Reassessments/Ongoing assessments are completed ...; or following a significant event ..."

Closed medical record review of Patient #3 revealed a 66-year-old male was admitted to the facility on 11/28/2020 at 0304 with chief complaints of trauma – fall. Review of the History & Physical dated 11/28/2020 0625 revealed, "HPI (History of Present Illness): (named Patient #3)... presents as a Level 2 trauma activation after sustaining injuries in a fall earlier this evening ... When the patient arrived, he was GCS 14(Glasgow Coma Scale – scale used to assess level of consciousness; scores range from 3 (lowest) to 15 (highest level of consciousness)), ABC (Airway, Breathing, Circulation) intact, and hemodynamically(blood flow in circulation) stable ... Impression: ...Found to have the following injuries: - L (left) SDH (subdural hematoma- bleeding underneath the dural membrane(connective tissue that surrounds the brain and spinal cord)) 10 mm (millimeter) with midline shift – SDH/SAH (subarachnoid hemorrhage - bleeding within the subarachnoid space(space between the brain and skill that contains cerebrospinal fluid)) in frontal R (right) convexity(curvature of the front of the brain) – Occipital bone fracture. Recommendations: Patient to go to OR (operating room) ..." Medical Record Review revealed Patient #3 was transferred from an intensive care unit to a neurology unit on 12/04/2020 at 2111. Review of the Nursing Notes dated 12/04/2020 at 2344 revealed, "Per CNA (Certified Nurse Assistant) (named CNA #2) Bed alarm went off and she ran to patient ' s room, she heard a loud thud and found patient kneeling on the floor and in the process of trying to climb back in the bed ... MD paged. Dr. (named MD #3) at the bedside. After he (MD #3) did a thorough assessment on patient..." Medical record review revealed Patient #3 expired on 12/15/2020 at 1300 at the facility. Review of the Plan of Care failed to reveal updates from 12/04/2021 (date of the unwitnessed fall) through 12/06/2021. Medical record review failed to reveal documentation of the physician ' s post fall assessment and the nurse ' s post fall assessment for Patient #3.

Interview on 07/28/2021 at 1615 with RN #1 revealed they assumed nursing care for Patient #3 on the night of 12/04/2020. Interview revealed Patient #3 had an unwitnessed fall at approximately 2300 (two hours after arrival to the unit). Interview revealed 12/04/2020 was a "busy night" and that RN #1 completed a nursing note and event report system entry. Interview revealed Patient #3 was assessed by medical and nursing staff. Interview revealed the post fall assessments were not documented.

Interview on 07/29/2021 at 0845 with CNA #2 revealed she found Patient #3 after his unwitnessed fall on the night of 12/04/2020. Interview revealed documentation of the fall and assessments were deferred to the primary nurse caring for Patient #3.

Interview on 07/29/2021 at 0910 with MD #3 revealed they were paged to assess Patient #3 after his unwitnessed fall on the night of 12/04/2020. Interview revealed Patient #3 was assessed and the assessment findings were discussed with the House Officer. Interview revealed the post-fall assessment findings were not documented immediately after assessment by MD #3.

Interview on 07/29/2021 at 1005 with NM (Nurse Manager) #4 revealed the expectation was that nursing staff documented their assessments of patients after a change in condition or an event. Interview revealed the RN should have documented their post fall assessment findings in the EHR and event reporting system.

Interview on 07/29/2021 at 1320 with MD #5 revealed the expectation was that residents document post- fall assessment in the EHR. Interview revealed the post-fall assessment and findings from the resident should be documented in a "POC (plan of care) note or event note".