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Based on medical record review, observations, policy review and interview, the facility failed to ensure nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs (A396).

Based on medical record review, observations, policy review and interview, the facility failed to ensure nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs for four patients assessed as at high risk for falls (Patients #1, #4, #9 and #10). A total of ten medical records were reviewed. The facility's census at the time of the survey was 396.

Findings include:

Review of the facility's Fall Minimization and Post Fall Care, Adult Protocol (Version 1, Effective 02/19/20) revealed the purpose was to define nursing's role in the management of patients at risk for falls and post fall care. NOTE: This document provides a universal protocol that applies to all patients.

Protocol Statement
1. Registered Nurses (RNs)/Licensed Practical Nurses (LPNs)/Ambulatory Clinical Staff screen for fall risk according to location specific criteria.
2. If the patient is deemed to be at a higher risk than identified by the scale score, reclassification to a higher risk category may be done (RN professional judgment). The RN/LPN/Ambulatory Clinical Staff may not classify the patient to a lower risk category than measured by the scale.
3. Universal fall precautions are used for all patients. Moderate and high-risk interventions are selected based on individual patient needs or by scale score or as in #2 above.

Listed under Fall Minimization and Post Fall Care, Adult Protocol-Inpatient High Risk Patient Identification Interventions was the following:
6) Inpatient (Mandatory): for High Risk
a) Place high fall risk symbol on doorframe/curtain outside patient's room, ensure it is removed upon patient discharge.
b) Place a yellow Fall Risk band on same extremity as patient's ID (identification) band.
- Other care areas requiring a patient ID band will also utilize the yellow Fall Risk band.
- Ensure appropriate non-skid footwear at all times, consider the use of double tread yellow slipper socks to identify patient as high fall risk.
c) Utilize "Call before you clean up or stand up" signage in the bathroom for all high risk patients (excludes behavioral health).
d) Bathroom/bedside commode precautions for all high risk patients:
- Remain outside of the bathroom door/curtain while patient is toileting for all high fall risk patients.
- Caregiver will remain outside of the bathroom door ("foot in door") with the door cracked/outside of curtain with curtain cracked so that you can see into the bathroom/see bedside commode.

1. Review of Patient #1's medical record revealed on 08/31/21 at 7:55 AM, Staff Q increased Patient #1's Hester Davis Fall Risk Assessment Scale from a score of 14 (a score of 11-14 was a moderate risk) to high risk for falls per registered nurse professional judgement.

On 08/31/21 at 8:59 PM, Staff R documented Staff R was unaware Patient #1 was on the bedside commode alone. Patient #1 was left unattended by staff that helped her to the commode. At 8:25 PM, Patient #1 was found by Staff R on floor laying on her right side and bleeding from the head.

The findings were confirmed in an interview by Staff P on 11/03/21 at 4:53 PM.

2. During tour of the facility on 11/02/21, the outside of Patient #4's room was observed at 10:45 AM. A high fall risk symbol was not present on the doorframe. Review of Patient #4's medical record revealed the patient was assessed as being high risk for falls on 11/02/21 at 8:48 AM. Patient #4 was observed without a yellow Fall Risk band.

The findings were confirmed in an interview by Staff M on 11/02/21 at 10:45 AM.

3. During tour of the facility on 11/02/21, the outside of Patient #9's room was observed at 11:32 AM. A high fall risk symbol was not present on the doorframe. Review of Patient #9's medical record revealed the patient was assessed as being high risk for falls on 11/02/21 at 9:15 AM.

The findings were confirmed in an interview by Staff N on 11/02/21 at 11:32 AM.

4. During tour of the facility on 11/02/21, the outside of Patient #10's room was observed at 11:46 AM. A high fall risk symbol was not present on the doorframe. Review of Patient #10's medical record revealed the patient was assessed as being high risk for falls on 11/02/21 at 8:45 AM.

The findings were confirmed in an interview by Staff O on 11/02/21 at 11:46 AM.