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Based on interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, "Patient Fall Assessment and Post Fall Assessment," for one of 32 sampled patients (Patient 1) when Patient 1 was left unattended by staff in the restroom. This failure resulted Patient 1's fall and a break of the left side of the pubic bone (one of the three main bones that make up the pelvis, a structure located between the abdomen and thigh).

Findings:

During a review of Patient 1's "HOSPITALIST HISTORY AND PHYSICAL (H&P)," dated 8/9/25, the H&P indicated, Patient 1's history of present illness "prior frequent falls who presented to the ED [emergency department] with intractable [difficult pain to manage] right hip pain after a ground-level fall on 8/4/25."

During a review of "CT [computed tomography-imaging technique that uses x-ray to create detailed, cross-sectional images of bones, organs and soft tissue] ABDOMEN 7 [AND] PELVIS," dated 8/5/25, the CT indicated, a break in right inferior (position) pubic ramus (portion of the pelvic bone).

During a review of Patient 1's "Daily Assessment Inquiry (DAI-Morse Fall Risk [MFS] assesses fall risk. A score greater than or equal to 50 is considered a high fall risk)," dated 8/16/25 at 8:20 a.m. The DAI indicated Patient 1's MFS score was 75.

During an interview on 9/16/25 at 9:50 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 8/16/25 Patient 1 was taken to restroom by the charge nurse, and I walked in while Patient 1 was on toilet, I relieved charge nurse. LVN 1 stated after Patient 1 finished using the bathroom, Patient 1 was standing at the sink with her walker, she washed her hands and wanted to brush her teeth. LVN 1 stated while Patient 1 was standing, LVN 1 walked out of bathroom to change gloves. LVN 1 stated she observed Patient 1 "stumbling" in the bathroom. LVN 1 stated Patient 1 started falling back and hit her back of the head on the handrail in the bathroom and fell to the floor. LVN 1 stated now looking back I should have stayed with Patient 1. LVN 1 stated it was not safe to leave Patient 1 in the bathroom alone. LVN 1 stated Patient 1 should not be left alone in the bathroom if Morse Fall risk score is over 50.

During a review of "CT PELVIS," dated 8/16/25, the CT indicated, breaks in right and left side of the pubic bone.

During a review of the facility's P&P titled, "Patient Fall Assessment and Post Fall Assessment" dated 9/8/2014, the P&P indicated, "A fall is defined as an "Unplanned descent to the floor with or without injury to the patient". . .b. Increased Fall Risk Precautions: MFS [Morse Fall Scare > [more than] 50. . .9. Any patient with a MFS >50 should never be left alone in the bathroom. . .C. Management of the Patient who has fallen. . .1. Assess and record vital signs and neurologic assessment hourly for four (4) hours then every four hours for 48 hours."

Based on interview, and record review, the facility failed to follow its Policy and Procedure (P&P) titled "Pain Management" for eight of 32 sampled patients (Patient 4, Patient 11, Patient 3, Patient 14, Patient 18, Patient 24, Patient 31, and Patient 30) when effective of pain medication was not assessed. This failure had the potential for patients Patient 4, Patient 11, Patient 3, Patient 14, Patient 18, Patient 24, Patient 31, and Patient 30 to not have effective pain control.

Findings:

During a concurrent interview and record review on 9/16/25 at 1:40 p.m. with Registered Nurse (RN) 1, Patient 4's "Medication Admin (MAR)," dated September 2025 was reviewed. The MAR indicated, Tylenol (mild pain medication) 650 mg (milligram-unit of measurement) was given on 9/10/25 at 2:55 p.m. RN 1 stated there was no documentation that a reassessment of Patient 4's pain level was completed after the pain medication was given.

During a concurrent interview and record review on 9/16/25 at 1:50 p.m. with RN 1, Patient 11's MAR, dated September 2025 was reviewed. The MAR indicated that Tylenol 650 mg was given on 9/16/25 at 11:21 a.m. RN 1 stated there was no documentation that a reassessment of Patient 11's pain level was completed after the pain medication was given.

During a concurrent interview and record review on 9/16/25 at 2 p.m. with RN 1, Patient 3's MAR dated September 2025 was reviewed. The MAR indicated that Tylenol 650 mg was given on 9/7/25 at 2:15 p.m. RN 1 stated there was no documentation that a reassessment of Patient 3's pain level was completed after the pain medication was given.

During a concurrent interview and record review on 9/17/25 at 10:30 a.m. with Quality Manager (QM) 1, Patient 14's "Medication Administration History Report (MAHR)," dated February 2025 was reviewed. The MAHR indicated Tylenol 650 mg was given on 2/27/25 at 10:20 a.m. QM 1 stated there was no documentation that a reassessment of Patient 14's pain level was completed after the pain medication was given.

During a concurrent interview and record review on 9/17/25 at 11:10 a.m. with QM 1, Patient 18's MAHR, dated June 2025 was reviewed. The MAHR indicated Hydrocodone-Acetaminophen (potent, highly addictive pain medication) 5-325 mg was given on 6/17/25 at 4:39 p.m. QM 1 stated there was no documentation that a reassessment of Patient 18's pain level was completed after the pain medication was given. QM 1 stated medication should be followed up within 1 hour after administration.

During a concurrent interview and record review on 9/17/25 at 11:55 a.m. with QM 1, Patient 24's MAHR, dated 6/17/25 was reviewed. The MAHR indicated Hydrocodone-Acetaminophen 5-325 mg was given on 6/17/25 at 8:25 a.m. QM 1 stated there was no documentation that a reassessment of Patient 24's pain level was completed after the pain medication was given, QM 1 stated medication should be followed up within 1 hour after administration.

During a concurrent interview and record review on 9/17/25 at 1:30 p.m. with QM 1, Patient 31's MAHR, dated December 2024 was reviewed. The MAHR indicated Tylenol 650 mg was given on 12/17/24 at 6:27 p.m. QM 1 stated there was no documentation that a reassessment of Patient 31's pain level was completed after the pain medication was given.

During a concurrent interview and record review on 9/17/25 at 2 p.m. with QM 1, Patient 30's MAHR, dated March 2025 was reviewed. The MAHR indicated Hydrocodone-Acetaminophen 5-325 mg was given on 3/22/25 at 2:52 p.m. QM 1 stated there was no documentation that a reassessment of Patient 30's pain level was completed after the pain medication was given. QM 1 stated medication should be followed up within 1 hour after administration.

During a review of the facility's P&P titled, "Pain Management" [undated], the P&P indicated, "All patients will receive the best level of pain control that can be provided safely. . .The effectiveness of interventions and results (response to pain intervention) will be documented by the licensed personnel within one hour following medications."

During a review of the facility's P&P titled, "Nursing Services (Swing Beds)," dated 11/14/23 the P&P indicated, "f Pain management. 13 Residents will routinely be monitored for levels of pain and discomfort using both verbal and non- verbal scales and receive appropriate care to treat their discomfort to an acceptable level using pharmacological interventions (as ordered by the ordering practitioner), and non-pharmacological interventions."