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Based on interview, record review, and review of facility policy it was determined the facility failed to provide necessary care and services for four of ten patients selected for review (Patients #6, #7, #8 and #9). On 05/17/12, Patient #9 sustained a fall and the Advance Registered Nurse Practitioner (ARNP) assessed the patient to have no injuries. Patient #9 complained of pain to the left leg/hip and received Tylenol for the complaints of pain on five occasions between 05/20/12 and 05/23/12. The physician was not notified of Patient #9's change in condition until 05/23/12, at which time an x-ray was obtained and the patient was identified to have a fractured left hip. In addition, the facility failed to ensure staff followed the facility's policy related to "Fall Prevention." According to facility policy, staff was to follow specific criteria for those patients identified to be at risk for falls. At the time of the investigation, documentation revealed staff failed to ensure the specific criteria identified in the policy had been meet for five of ten sampled patients identified by the facility to be at risk for falls.

The findings include:

Review of the facility's policy titled "Fall Prevention" dated 11/19/11, revealed the facility had a fall risk assessment tool to assess each patient's level of risk for falls and implement fall preventions/injury reduction interventions as appropriate. According to the policy, all patients were assessed upon admission and, when the patient's clinical status changed, for their potential for falls. In addition to fall prevention/injury reduction intervention, additional interventions for Low Risk Falls included: "A. Patients were to wear a yellow risk band or alternative method. B. Room placement designated with appropriate visual reminder of fall risk. C. Bed in low position with wheels in lock position. D. Label Kardex as fall risk. E. Offer toilet as needed. F. If unable to ambulate, reposition every two (2) hours. F. Reinforce safety precautions. G. Non-skid footwear in yellow fall precaution color."

Review of the facility's policy titled "Reassessment of psychiatric patient," dated October 2007, revealed the facility had a policy in place for Nursing Services to perform a complete reassessment of the patient every shift. Further review of the policy revealed any significant change in the patient's diagnosis and/or condition would necessitate an immediate reassessment with changes in the plan of care reflecting the change in diagnosis/condition. According to the policy, Nursing determined and prioritized the patient's nursing care needs.

Review of the incident report dated 05/17/12, revealed Patient #9 was found lying on the floor at approximately 9:45 AM. Further review of the incident report revealed the patient was wearing non-slip socks, confused, and picking at the air. According to the incident report, Patient #9 was assessed by the ARNP to have no injuries. Contributing factors related to the fall were suspected to be withdrawal for Benzodiazepines (anti-anxiety medication). The ARNP ordered staff to provide "1:1" supervision of the patient while he/she was awake for the patient's safety.

Interview with the Nurse Aide on 06/29/12, at 2:00 PM, confirmed Patient #9 had been found lying in the hallway on 05/17/12. The Nurse Aide stated Patient #9 was assessed by the ARNP to have no injuries.

Patient #9's medical record was reviewed on 06/27/12. Review of the initial nursing assessment dated 05/15/12, revealed Patient #9 was ambulatory with no deficit related to falls. On 05/17/12, Patient #9 was placed on "1:1" supervision for safety after being assessed by the ARNP to have unsteady gait. Review of the medication administration record revealed for three to six days after the fall Patient #9 received Tylenol (non-narcotic analgesic) for complaints of left leg/hip pain on five occasions between 05/20/12 and 05/23/12. There was no evidence the physician was notified of Patient #9's change in condition until 05/23/12, six days after the patient's fall. Review of the nursing note dated 05/23/12, revealed the nurse assessed Patient #9 and noted the patient's left foot turned outward. The physician was notified of the patient's complaints and an x-ray was obtained which revealed the patient sustained an acute fracture of the left hip. Further review of the medical record revealed Patient #9 was transferred to the medical floor on 05/23/12, and the patient underwent hip surgery.

The ARNP acknowledged in interview conducted on 06/28/12, at 10:45 AM, that Patient #9 had been found lying in the hallway of the facility on 05/17/12, at approximately 9:45 AM, and had been assessed to have no injuries. The ARNP stated staff was asked to provide "1:1" supervision of the patient for his/her safety, and the patient was placed in a wheelchair due to his/her unsteady gait. The ARNP denied any knowledge that Patient #9 had complained of left leg/hip pain following the incident. The ARNP stated RN #4 reported on 05/23/12, that Patient #9's left foot turned outward and an x-ray was ordered which revealed a fractured left hip.

Interview with Patient #9's attending physician on 06/28/12, at 10: AM, revealed the physician did not recall being informed of the patient's fall and was not aware Patient #9 had experienced left leg/hip pain. The physician recalled discussing Patient #9 in team meeting and understood the patient was placed on "1:1" supervision due to the possibility of the patient experiencing possible benzodiazepines withdrawal/mental status change.

Interviews on 06/28/12, at approximately 11:15 AM, with the radiologist that performed the x-ray of Patient #9 and the surgeon that performed the patient's surgery revealed Patient #9's fracture was "acute" and consistent with a fall. It was the surgeon's professional opinion that the fracture had occurred during the patient's hospitalization.

In addition, a tour of the Psychiatric Unit (Mountain Unit) was conducted on 06/28/12, at 4:30 PM. A review of documentation revealed three patients (Patients #6, #7, and #8) were identified to be at risk for falls and the patients' medical records had been flagged to identify the patients were at risk for falls. However, observation at the time of the tour revealed the facility failed to ensure staff followed the facility's policy/protocols. Patient #6 and Patient #7 were not wearing yellow socks or a yellow arm band as identified in the facility's fall risk protocol. Further observation during the tour revealed Patient #8, who had been identified as a fall risk, was not wearing yellow socks as indicated in the protocols for falls.