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Based on staff interview and document review, it was determined that nursing staff failed to implement the interventions outlined in the patient's plan of care in one (1) of eight (8) medical records reviewed in the survey sample. Specifically, nursing staff failed to implement fall prevention measures outlined in Patient #2's plan of care.

Findings:

The medical record for Patient #2 contained documentation that the patient was transferred from an outside hospital on February 8, 2024 with new onset seizure activity. Documentation indicated the patient had altered mental status and was intubated and sedated on February 8, 2024. On February 09, 2024, the patient was extubated and alert, but confused. On February 10, 2024 Patient #2 was transferred from the ICU (intensive care unit) to a medical floor where the patient's mental status continued to be documented as confused with difficulty answering questions. The record contained documentation that on February 11, 2024 the patient was more alert and waiting on evaluation from physical and occupational therapy.

The nursing assessment from February 11, 2024 at 12:49 PM contained documentation from the Registered Nurse (RN) that the patient was "bedfast" with no out of bed activity and transferring status was documented as "immobile." The RN documented that Patient #2 was a "high" fall risk and the following interventions were to be implemented: "low bed, bed/chair alarm, slow position changes...supervised toileting."

The RN documented the following on February 11, 2024 at 5:52 PM: "Patient's bed alarm went off. I went in and [patient] said they needed to use the restroom (bowel movement). I assisted the patient to the restroom. Patient sat safely on toilet. Patient was informed to pull emergency string when they were finished using the restroom. Myself and patient's sister began to talk and I heard a loud noise. When I went into the restroom, patient was on the floor..."

An interview was conducted on October 28, 2024 with Staff Member #13 at 2:00 PM. Staff Member #13 stated that if a patient is identified as a high fall risk, the patient should not be left unattended in the bathroom unless the patient requests privacy. The medical record for Patient #2 did not contain documentation that the patient requested to be alone in the bathroom.

The medical record for Patient #2 contained no documentation that the patient's mobility/ambulation status had been re-evaluated by nursing on February 11, 2024 after documentation that the patient was "bedfast" and "immobile" at 12:49 PM. It was unclear from the medical record and patient's plan of care whether or not the patient could safely ambulate and what assistance if any they required. The medical record for Patient #2 contained no documentation of the reason the patient was left unattended in the bathroom after being identified as a high fall risk and why the care planned intervention of supervised toileting was not implemented.

The facility's policy, Fall prevention policy was reviewed and reads in part: Each patient will have a fall scale score and risk level documented within the Electronic Health Record...2. Following the calculation of a fall score and risk level, the nurse will document all active, applicable interventions pursuant to the individual needs of each patient. 3. Every patient should have fall prevention measures listed as part of their individualized plan of care.