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Based on review of facility policies and procedures, medical record review and staff interview, staff failed to notify a patient's family of an injury sustained by the patient falling for one of one records reviewed of patient falls with injury (#3).

Findings include:

Review of facility policy "Patient Bill of Rights" dated 11/2010 on 5/19/2011 revealed "A patient has the right to:...Make decisions regarding his or her care, including the right to involve family members in those decisions, Give or withhold informed consent. The patient has the right to receive information from his or her doctor in order to make informed decisions about his or her care. This means that patients will be given information about their diagnosis, prognosis and different treatment choices...Have a surrogate decision-maker make decisions about his/her care, treatment and services, including the right to refuse care, treatment or services, on the patient's behalf if patient is unable to do so..."

Medical record review for Patient #3 on 5/18/2011 revealed an 85 year old admitted 01/12/2011 through the facility's Emergency Department for altered mental status, metastasis, acute renal failure, hyperkalemia (high blood potassium), diabetes and urinary tract infection. Review of the nursing admission assessment dated 01/12/2011 at 0252 revealed contact information obtained from family. Review of nursing documentation on 01/14/2011 at 0347 revealed "Pt heard yelling "help." Upon entering room pt. noted to be on the floor face down (symbol for "with") head against chair leg. (Symbol for"No") abnormal alignment of limbs noted. Pt. placed back in bed. (Symbol for "Change") in LOC (level of consciousness) noted. Pt. A&Ox2 (alert but not fully oriented) confused to place. States "I am @ the nursing home." Pupils noted to be round & non-reactive to light. (Symbol for "Left") eye contusion noted on brow bone 3cm (centimeters) diameter & approximately 1 inch elevation. IV infiltrated..." Further review of nursing documentation on 01/14/2011 at 1000 revealed "Pt's daughter arrived. She's (daughter) is very upset & irate that Pt fell OOB (out of bed)..."

Interview on 5/19/2011 at 0830 with the registered nurse (RN) documenting patient care on 01/14/2011 at 0347 revealed the patient sustained an injury from a fall out of bed while climbing over the bed siderails. Interview revealed the patient was disoriented during the assessment after the fall. Interview revealed the patient's family was not notified of the patient's fall with an injury. Interview revealed that due to the patient's confusion at the time of the fall was unable to make decisions for herself. Interview revealed the patient's family found out about the patient falling when they entered the room to visit later that morning and saw the patient's injury to the face (six hours and 13 minutes after the patient fell out of bed). Interview revealed "I was busy caring for the patient." Further interview revealed "I know now I should have called the family."

Based on review of facility policies and procedures, medical record review and staff interview, staff failed to prevent a fall with injury and failed to assess a patient for falls risk on admission for one of one records reviewed of patient falls with injury (#3).

Findings include:

A. Review of facility policy "Fall Prevention & Management Program: Morse Falls Risk Model" dated 12/2009 on 5/18/2011 revealed "II. Policy - (Name of facility) will provide a safe environment in which each patient receives care to minimize the risk of patient harm resulting from falls while ensuring the patient's right to maintain as much independence as possible. (Name of facility) will provide a mechanism by which each patient's level of risk for falls (low, moderate or high) will be assessed and preventive measures implemented as indicated." Further review revealed "C. Morse Fall Risk Assessment...3. Scoring and Risk Level...Patients with a Fall Risk Score of:...High Risk - 51 and higher - Implement High Risk (Level III) Strict Fall Precautions." Review revealed "F. High Risk (Level III) Strict Fall Precautions...4. Consider bed alarm..."

Medical record review for Patient #3 on 5/18/2011 revealed an 85 year old admitted 01/12/2011 through the facility's Emergency Department for altered mental status, metastasis, acute renal failure, hyperkalemia (high blood potassium), diabetes and urinary tract infection. Review of the physician History and Physical dated 01/11/2011 at 2254 revealed "Social History:...She states she ambulates with a walker." Review of the Morse Fall Risk assessment on 01/13/2011 at 1934 revealed "History of falls - No = 0, Secondary Diag(nosis) - Yes = 15, Ambulatory Aid - NA = 0, IV/Saline Lock - Yes = 20, Oxygen - Yes = 20, Gait/Transferring - Nrm(Normal) = 0, Mental Status - Orient ability = 0, Score = 55 (symbol for "greater than") 51 High Risk." Review of the Medication Administration Record for 01/14/2011 revealed at 0010 the patient was administered Lorazepam 0.5 milligrams (anxiety medication) and at 0137 was administered Zolpidem Tartrate 5 milligrams (sleep aide). Review of nursing documentation on 01/14/2011 at 0347 revealed "Pt heard yelling "help." Upon entering room pt. noted to be on the floor face down (symbol for "with") head against chair leg. (Symbol for"No") abnormal alignment of limbs noted. Pt. placed back in bed. (Symbol for "Change") in LOC (level of consciousness) noted. Pt. A&Ox2 (alert but not fully oriented) confused to place. States "I am @ the nursing home." Pupils noted to be round & non-reactive to light. (Symbol for "Left") eye contusion noted on brow bone 3cm (centimeters) diameter & approximately 1 inch elevation. IV infiltrated..." Further review of flowsheet nursing documentation of the section "Alarm Bed on" on 01/14/2011 from 0000 - 0600 failed to reveal any documentation that the bed alarm was on during the time period.

Interview on 5/19/2011 at 0830 with the RN documenting patient care on 01/14/2011 at 0347 revealed the patient was given a high risk score during the beginning of the shift assessment. Interview revealed the patient stated she was feeling anxious around midnight on 01/14/2011 and was given the dose of lorazepam. Interview revealed at 0137 was given the sleep aide medication per patient request that she was unable to sleep. Interview revealed the patient was sleeping until 0347 when the RN was at the nurse's station and heard a loud noise come from the direction of Patient #3's room then heard the patient yell "help". Interview revealed upon entering the room, the RN assessed that the patient sustained an injury from a fall out of bed while climbing over the bed siderails. Interview revealed the patient was disoriented during the assessment after the fall. Further interview revealed the bed alarm did not sound to alert staff the patient was attempting to exit the bed. Interview revealed that since the patient was scored a level III, high risk for falls, the bed alarm was supposed to be on. Interview revealed after questioning other staff, the bed alarm had been cut off and not turned back on after cleaning the patient up in the two hour timeframe just prior to the fall. Interview revealed "Someone forgot to turn the bed alarm back on." Interview revealed staff failed to prevent a fall with injury by failing to implement falls precautions measures such as ensuring the available bed alarm was on to alert staff a patient was attempting to exit the bed.

B. A. Review of facility policy "Fall Prevention & Management Program: Morse Falls Risk Model" dated 12/2009 on 5/18/2011 revealed "Procedure...A. Fall Risk Assessment - 1. The patient will be assessed for fall risk on admission and documented on the medical record."

Medical record review for Patient #3 on 5/18/2011 revealed an 85 year old admitted 01/12/2011 through the facility's Emergency Department for altered mental status, metastasis, acute renal failure, hyperkalemia (high blood potassium), diabetes and urinary tract infection. Review of the nursing admission assessment dated 01/12/2011 at 0252 failed to reveal any assessment of falls risk.

Interview on 05/19/2011 at 0815 with the registered nurse (RN) who completed the nursing admission assessment revealed there was no documentation in the record of the falls risk assessment being completed on admission. Interview revealed the staff member failed to follow facility policy by failing to document the completion of a falls risk assessment when the patient was admitted to the facility.