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Based on observation, interview, record review, and review of facility's policies, it was determined the facility failed to ensure patient rights were protected and promoted by failing to provide care and treatment in a safe setting for fifteen (15) of twenty-three (23) patients (Patients #5, #10 and #11 through #23). Patient #5 was admitted to the facility on 09/26/12 with diagnoses which included a Cerebral Vascular Accident (CVA). Patient #5 had left-sided weakness and was identified as a high fall risk per facility protocol from admission to transfer to an acute care facility on 10/04/12. Patient #5 was transferred for evaluation after sustaining an unwitnessed fall on 10/04/12; he/she was admitted to the acute care hospital and did not return to the facility. Patient #5 fell from his/her wheelchair and did not have a bed alarm or chair alarm being used at the time of the fall. Patient #10 was admitted to the facility on 07/31/12 with diagnoses which included Acute Respiratory Failure and Chronic Obstructive Pulmonary Disease (COPD). He/she was identified as a high fall risk per facility protocol from admission to transfer to an acute care facility on 08/11/12. Patient #10 was transferred for evaluation after sustaining an unwitnessed fall on 08/11/12. Patient #10 was attempting to get to the telephone per Occurrence Report and was found lying in the floor in front of the sink in his/her room and did not have a bed alarm or chair alarm activated at the time of the fall. Patient #10 was admitted to the acute care hospital and did not return to the facility. Review of facility policy and protocol on managing falls revealed all patients identified as high risk for falls would have bed and chair alarms utilized. In addition to Patients #5 and #10, thirteen (13) additional patients (Pt's #11 through #23), identified by the facility as high risk for falls, were observed not having bed and/or chair alarms being used in their care. The failure of the facility to ensure patient rights were protected and promoted and care was provided in a safe environment, placed patients at risk for serious injury, harm, impairment or death. The facility was notified on 10/24/12 that Immediate Jeopardy was determined to exist related to Patient Rights. The facility initiated corrective actions, and the Immediate Jeopardy was determined to be abated on 10/26/12, prior to exit on that date.

(Refer to A0144)

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure nursing services were provided according to the patients' nursing plan of care (POC) for fifteen (15) of twenty-three (23) patients (Patients #5, #10 and #11 through #23). Patient #5 was admitted to the facility on 09/26/12 with Diagnoses which included a Cerebral Vascular Accident (CVA). Patient #5 had left-sided weakness and was identified as a high fall risk per facility protocol from admission to transfer to an acute care facility on 10/04/12. Patient #5 was transferred for evaluation after sustaining an unwitnessed fall on 10/04/12; he/she was admitted to the acute care hospital and did not return to the facility. Further record review revealed Patient #5 expired on 10/19/12. Patient #5 fell from his/her wheelchair and did not have a bed alarm or chair alarm being used at the time of the fall. Patient #10 was admitted to the facility on 07/31/12 with Diagnoses which included Acute Respiratory Failure and Chronic Obstructive Pulmonary Disease (COPD). He/she was identified as a high fall risk per facility protocol from admission to transfer to an acute care facility on 08/11/12. Patient #10 was transferred for evaluation after sustaining an unwitnessed fall on 08/11/12. Patient #10 was attempting to get to the telephone per Occurrence Report and was found lying in the floor in front of the sink in his/her room and did not have a bed alarm or chair alarm activated at the time of the fall. Patient #10 was admitted to the acute care hospital and did not return to the facility. Review of facility policy and protocol on managing falls revealed all patients identified as high risk for falls would have bed and chair alarms utilized. These were interventions listed in the nursing plan of care (POC) for high risk fall patients. In addition to Patient #5 and #10, thirteen (13) additional patients (Patients #11 through #23), identified by the facility as high risk for falls, were observed not having bed and/or chair alarms being used in their care. The failure of the facility to ensure nursing services were provided according to the nursing (POC), placed patients at risk for serious injury, harm, impairment or death. The facility was notified on 10/24/12 that Immediate Jeopardy was determined to exist related to Nursing Services. The facility initiated corrective actions, and the Immediate Jeopardy was determined to be abated on 10/26/12, prior to exit on that date.

(Refer to A0396)

Based on interview and review of the facility booklet, "Guide to Patient Services, Physical Rehabilitation at its Best!," undated, it was determined the facility failed to ensure the Kentucky Office of Inspector General's telephone number was given to all patients for them to register a complaint/grievance with this agency, if they determined their care was inadequate or substandard.

The findings include:

Review of the facility booklet, "Guide to Patient Services, Physical Rehabilitation at it Best!," undated, page 10, Section "Grievance Procedure" revealed there was no information, including telephone number, given to patients about filing a complaint/grievance with the Kentucky Office of Inspector General.

Interview with the Nursing Practice Coordinator, on 10/19/12 at 12:00 PM, revealed the above booklet was given upon admission to patients and/or families. She stated this was the only information given to patients concerning the grievance procedure and agreed that the Kentucky Office of Inspector General's telephone number, with the instruction that patients could file a grievance with this agency, was missing from the booklet and not given to patients in any other document.


ANY INTERVIEWS WITH PATIENTS RELATED TO THIS?

Based on interview and review of the facility's policy, "Client Grievance or Right to Appeal," number P04, reviewed and revised 07/2009, it was determined the facility failed to ensure a written response was given, for all patients who filed a grievance.

The findings include:

Review of facility's policy, "Client Grievance or Right to Appeal," number P04, reviewed and revised 07/2009, revealed the policy did not direct a written response to be given to the patient that filed a grievance with the facility. The policy only mandated verbal responses to be given at each phase of handling the grievance.

Interview with the Nursing Practice Coordinator, on 10/19/12 at at 12:00 PM, revealed there was no process for giving a written response to the patient when a grievance was filed. The facility policy was followed which provided for the "Client Complaint Form" to be completed, but the patient did not get a copy or get a letter detailing actions taken to deal with the grievance.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure patient rights were protected and promoted by failing to provide care and treatment in a safe setting for fifteen (15) of twenty-three (23) sampled patients (Patients #5, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22 and #23). The facility failed to ensure staff was implementing interventions required for patients identified as high risk for falls.

The findings include:

Review of the facility's policy, "Falls: Risk Assessment/Management," revised 09/2012, revealed the admitting Registered Nurse (RN) was responsible for ensuring the Fall Risk Assessment (FRA) was completed initially using the Fall Risk Assessment Tool approved at the Senior Management Meeting of 08/11/10. Then, every shift, or three times daily, it would be done again by the RN assigned to the patient to determine if there needed to be a reclassification of risk category, general risk or high risk. The Fall Risk Assessment Tool revealed there were seven (7) categories that were scored. These categories were 1) age; 2) fall history; 3) mobility; 4) elimination; 5) mental status change; 6) medications; and 7) client care equipment with tubing present. With this instrument, the higher the score, the greater the risk of a fall. The policy further revealed a score of fifteen (15) or above indicated a high risk and would trigger interventions to prevent falls from occurring. One of these high risk interventions was the requirement to use bed and chair alarms.

1. Review of the clinical record of Patient #5 revealed the facility admitted the patient on 09/26/12 with diagnoses which included Cerebral Vascular Accident (CVA) with left sided hemiplegia. Treatment included physical therapy, occupational therapy and speech therapy daily. Medications included anticoagulation therapy of Enoxaparin 80 milligrams (mg) subcutaneously (SC) twice a day and Warfarin orally; the dose titrated to laboratory results that measured blood clotting time. The patient received seven (7) mg of Warfarin on 10/03/12. The physical therapy note of 10/04/12 at 8:40 AM revealed Patient #5 did not ambulate and required total assistance with the use of a wheelchair. Further review revealed the patient was identified as a high fall risk with a score of nineteen (19). Review of nurses' notes from 10/04/12 and facility Occurrence Report No. 34154, dated 10/04/12, revealed Patient #5 fell from his/her wheelchair, on 10/04/12 at 12:40 PM, and sustained a laceration over the left eye with a large amount of swelling and bleeding. The Occurrence Report further revealed Patient #5 did not have a chair alarm on at the time of the fall. The record stated the patient was transferred to an acute care hospital emergency department (ED) for further evaluation.

Review of the clinical record of Patient #5 from the acute care facility where the patient arrived, on 10/04/12 at 2:08 PM via ambulance, revealed the patient was oriented with a pain rating of five (5) on a zero (0) to ten (10) pain scale and a Glasgow Coma Scale (GCS: a score given to indicate neurological functioning; the lower the score, the more neurologically compromised) score of fifteen (15). Initial Computerized Tomography (CT) scan of the head showed a small parenchymal hemorrhage in the paramedian portion of the right posterior frontal lobe. A complete blood count (CBC), on 10/04/12 at 3:01 PM, showed a platelet count of forty-four thousand (44,000) which was low, (normal range was 150,000 to 400,00). Two (2) units of Fresh Frozen Plasma (FFP) were ordered 10/04/12 at 3:59 PM, 7:58 PM and 10:18 PM. Record review revealed these six (6) units were given. Two (2) units of Platelets were ordered on 10/04/12 at 5:28 PM and 11:49 PM. Record review revealed these four (4) units were given (Both FFP and Platelets are blood components given to aid in blood clotting.) Review of the ED Hourly Rounding nurses' notes revealed no problems 10/04/12 at 9:00 PM; however, by 10:25 PM, Patient #5 had an altered mental status, was unable to follow commands, was disoriented and had a GCS score of nine (9), meaning the patient was neurologically deteriating. At 1:11 AM on 10/05/12, the notes reveal the patient continued to decline with labored breathing and a fixed pupil of four (4) millimeters (mm) in the right eye. The GCS score was six (6). Patient #5 was intubated and placed on a ventilator. CT scan of the head, on 10/05/12 at 4:44 AM, revealed progressive hemorrhages with active bleeding and a persistent subarachnoid hemorrhage. On 10/05/12 at 3:35 PM, Patient #5 was placed in an Intensive Care Unit (ICU) bed. On 10/15/12, the family of the patient decided to place the patient in a Do Not Resuscitate (DNR) status, and he/she was extubated. On 10/16/12, Patient #5 was discharged to a hospice unit with terminal diagnoses of subarachnoid hemorrhage and subdural hematoma due to a fall sustained at the facility on 10/04/12. Review of the hospice clinical record of Patient #5 revealed he/she expired on 10/19/12.

Interview with Physical Therapist #1, on 10/24/12 at 2:14 PM, revealed she discovered Patient #5, on 10/04/12 at 12:40 PM, face down on the floor. The patient was between the wheelchair and the bed, and the wheelchair was three (3) or four (4) feet from the bed. Physical Therapist #1 stated there was a lot of blood on the floor. She revealed six (6) people came into the room and lifted Patient #5 onto the bed. Physical Therapist #1 stated she left the room when Patient #5 had been lifted into the bed.

Interview with Registered Nurse (RN) #1, on 10/24/12 at 1:40 PM, revealed she was Patient #5's nurse on 10/14/12 at 12:40 PM when Patient #5 fell from his/her wheelchair. RN #1 stated Patient #5 had asked to go back to bed while sitting in his/her wheelchair. However, RN #1 revealed she delayed putting Patient #5 into bed at that time because it was time for his/her bolus nasogastric (NG) tube feeding and medications per NG tube were due. Therefore, she stated she believed it would be better for the patient to remain sitting up. RN #1 further revealed she then left Patient #5's room for fifteen (15) to thirty (30) minutes to prepare the feeding and medications. She further stated Patient #5's seat belt was not fastened when he/she fell. Also, RN #1 stated Patient #5 did not have a chair alarm in use. She also stated she believed Patient #5 was safe to be in a wheelchair alone because the patient was not impulsive in his/her actions. RN #1 revealed she knew patients that were identified as a high fall risk should have bed and chair alarms in use, as per the facility's policy.

Interview with Nursing Unit Coordinator (NUC) #1, on 10/24/12 at 4:10 PM, revealed Patient #5 was at high risk for falls and should have had a bed and chair alarm in use but did not, as per the facility's policy.

2. Review of the clinical record of Patient #10 revealed the facility admitted the patient on 08/11/12 with diagnoses which included Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF) and Prostate Cancer. Treatment included daily physical therapy and occupational therapy for pulmonary rehabilitation. FRA on 08/11/12 at 11:52 AM showed a score of seventeen (17), indicating the patient was at high risk for falls. Review of the Rounding log, which was utilized to document hourly observations, revealed on 08/11/12 at 10:00 AM, 11:00 AM and 12:00 PM the log indicated neither the bed alarm nor chair alarm was in use, as per the facility's policy. Physical therapy notes, dated 08/11/12 at 10:00 AM, revealed Patient #10's oxygen saturation level was between seventy-eight (78) and eighty-nine (89) percent on three (3) liters of oxygen delivered by nasal cannula. Continued review of this noted revealed the therapy notes indicated Patient #10 transfers from bed to wheelchair and required moderate assistance of one (1). The physical therapy notes also stated that Patient #10's medical condition had declined over the past two (2) days.

Nursing progress notes, on 08/11/12 at 11:45 AM, revealed Patient #10 returned from Occupational Therapy (OT) and his/her oxygen saturation was ninety (90) percent on 2 liters of oxygen given by nasal cannula. The nurses' notes at 12:00 PM that day stated Patient #10 fell. The fall was also corroborated by Occurrence Report No. 34075, dated 08/11/12 at 12:00 PM. This report stated Patient #10 was found in his/her room, lying in the floor in front of the sink. He/she sustained a laceration to the upper lip with a minimal amount of bleeding. He/she also had a reddened area on the forehead. Patient #10 was sent to an acute care hospital ED for further evaluation.

Review of the clinical record of Patient #10 from the acute care facility where he/she was admitted on 08/11/12, revealed Patient #10 arrived at the facility via ambulance at 1:52 PM. CT scan of the head and facial bones while the patient was in the ED showed no acute changes. The two (2) centimeter (cm) laceration above the upper lip was repaired. Due to hypoxia (a partial pressure of oxygen of 32.7 on 2 liters of oxygen given by nasal cannula), the patient was admitted. The record revealed the admission was not due to injuries received during the fall at the facility. The record further revealed the patient underwent an aspiration of an abdominal lymph node which was consistent with metastatic adenocarcinoma. Aggressive therapy was not considered an option by the family; so, Patient #10 was discharged on 08/24/12 to home with a hospice consult.

Interview with RN #2, on 10/26/12 at 3:00 PM, revealed she had been caring for Patient #10 on 08/11/12 at 12 :00 PM when he/she fell. RN #2 stated she was making rounds and found Patient #10 lying in the floor in front of the sink. She stated she did not think Patient #10 had been identified or marked as a high fall risk. RN #2 further revealed she could not remember if Patient #10 had a bed or chair alarm in use, but she did not hear any alarm when the patient fell.

Interview with NUC #2, on 10/26/12 at 3:20 PM, revealed she discovered Patient #10 did not have a chair alarm on when he/she fell. She further revealed had Patient #10 returned to the facility on 08/11/12 post-fall instead of being admitted to the acute care facility, she would have ensured Patient #10 had both a bed and chair alarm in use, as per the facility's policy.


3. Observation of the General Rehab Unit (GRU) on 10/23/12 at 4:40 PM, revealed Patient #11 was sitting up in a chair but did not have a chair alarm in use. Review of the clinical record of Patient #11 revealed he/she was admitted on 10/02/12 with diagnoses which included a CVA and Insulin Dependent Diabetes Mellitus. The treatment plan included physical therapy, OT, and speech therapy (ST) daily. Patient #11's initial FRA score was twenty (20), and on 10/23/12 at 4:46 PM the score was eighteen (18), high risk, which indicated the patient needed a chair and bed alarm per the facility's policy.

4. Observation of the GRU, on 10/23/12 at 4:40 PM, revealed Patient #12 was sitting in a wheelchair but did not have a chair alarm in use. Review of the clinical record of Patient #12 revealed he/she was admitted on 10/13/12 with diagnoses which included Brain Metastases (status post craniotomy) and Depression. His/her treatment plan included physical therapy and OT daily. Review of the Nurses' notes, on 10/13/12 at 11:07 PM, revealed a Certified Nurse Assistant (CNA) found Patient #12 on the floor scooting toward the bathroom. The patient stated he/she had the call bell on for fifteen (15) minutes. He/she slid himself/herself to the floor, and he/she was not injured. The record revealed Patient #12's vital signs were within normal limits, and his/her Physician and family were notified of the fall. Patient #12's initial FRA score was fifteen (15), and on 10/23/12 at 4:00 PM it was seventeen (17), high risk, which per the facility's policy would require alarms to be applied.

5. Observation of the GRU, on 10/23/12 at 4:40 PM, revealed Patient #13 was lying in bed without a bed alarm in use. Review of Patient #13's clinical record revealed he/she was admitted to the facility on 10/20/12 with diagnoses which included a Ruptured Hepatic Cyst, Atrial Fibrillation (a heart arrhythmia) and General Debility. The treatment plan included physical therapy and OT daily. The initial FRA score was eighteen (18), and on 10/23/12 at 11:00 AM it was seventeen (17), high risk.

6. Observation of the GRU, on 10/23/12 at 4:40 PM, revealed Patient #14 was lying in bed with the bed alarm in use. However, there was no chair alarm being used when the patient got into the wheelchair. Review of the clinical record of Patient #14 revealed he/she was admitted on 10/13/12 with diagnoses which included a fractured left hip, status post surgical repair. Record review revealed Patient #14 had fallen at home which caused the fracture. He/she also had postop confusion and hyponatremia. The treatment plan included daily physical therapy, OT and ST. The admission FRA score was twenty-six (26), and on 10/23/12 at 3:57 PM it was twenty (20), high risk, which would indicate the use of a chair and bed alarm.

7. Observation of the GRU, on 10/23/12 at 4:40 PM, revealed Patient #15 was sitting up in a chair eating. There was no chair alarm in use. Review of Patient #15's clinical record revealed he/she was admitted on 10/20/12 with diagnoses which included a CVA, Coronary Artery Disease (CAD), Hypertension and Atrial Fibrillation. The initial FRA score was nineteen (19), and on 10/23/12 at 4:00 PM it was twenty-four (24), high risk, which would indicate the need for the intervention of a chair and bed alarm.

Interview with the Nurse Practice Coordinator (NPC), on 10/23/12 at 5:00 PM, revealed all high risk fall patients should have both a bed and a chair alarm in use. She further revealed if the patient was in bed and there was not a chair alarm in the pouch on the back of their wheelchair, the chair alarm was not being used.

Interview with NUC #1, on 10/24/12 at 4:10 PM, revealed Patient #11, #12, #13, #14 and #15 were high risk for falls and did not have bed or chair alarms being used on 10/23/12 at 4:40 PM as required per facility policy.

8. Observation of the Stroke Unit, on 10/23/12 at 5:50 PM, revealed Patient #16 was lying in bed without a bed alarm or chair alarm in use. Review of the clinical record of Patient #16 revealed he/she was admitted on 10/18/12 with diagnoses which included a CVA and CAD. The treatment plan included daily physical therapy, OT and ST. Admission FRA score was sixteen (16), and on 10/23/12 at 4:51 PM it was twenty-one (21), high risk.

9. Observation of the Stroke Unit, on 10/23/12 at 5:50 PM, revealed Patient #17 was in the dining room on the unit in his/her wheelchair. There was not a chair alarm in use. Review of the clinical record of Patient #17 revealed he/she was admitted on 09/14/12 with diagnoses which included a CVA and Insulin Dependent Diabetes Mellitus. Patient 317 was on Warfarin 1.5 mg daily. The treatment plan included daily physical therapy, OT and ST. Admission FRA score was nineteen (19), and on 10/23/12 at 9:00 AM it was eighteen (18), high risk.

10. Observation of the Stroke Unit, on 10/23/12 at 5:50 AM, revealed Patient #18 was in a wheelchair in his/her room. There was not a chair alarm in use. Review of the clinical record of Patient #18 revealed he/she was admitted on 10/12/12 with diagnoses which included Subarachnoid Hemorrhage and Subdural Hematoma, status post fall at home, and Hyponatremia. Patient #18 was on Enoxaparin 40 mg SC daily. The treatment plan included physical therapy, OT and ST daily. Admission FRA score was eighteen (18), and on 10/23/12 at 3:02 PM it was twenty-three (23), high risk.

11. Observation of the Stroke Unit, on 10/23/12 at 5:50 PM, revealed Patient #19 was lying in the bed in his/her room. There was no chair alarm in use. Review of the clinical record of Patient #19 revealed he/she was admitted on 10/18/12 with Diagnoses which included a CVA and Diabetes Mellitus, Type II. The treatment plan included physical therapy, OT and ST daily. Admission FRA score was sixteen (16), and on 10/23/12, it was twenty-four (24), high risk.

12. Observation of the Stroke Unit, on 10/23/12 at 5:50 PM, revealed Patient #20 was lying in the bed in his/her room. There was no chair alarm in use. Review of Patient #20's clinical record revealed he/she was admitted on 10/18/12 with diagnoses which included a CVA and COPD. The treatment plan included daily physical therapy, OT, ST, and to continue Warfarin orally and low dose Enoxaparin SC. Admission FRA score was twenty (20), and on 10/23/12 at 2:44 PM it was twenty (20), high risk.

13. Observation of the Stroke Unit, on 10/23/12 at 5:50 PM, revealed Patient #21 was lying in bed in his/her room. There was no chair alarm in use. Review of Patient #21 ' s clinical record revealed he/she was admitted on 10/19/12 with diagnoses which included a CVA and Atrial Fibrillation. The treatment plan included physical therapy, OT, ST and to continue long-term use of anticoagulants and low molecular weight heparin. Admission FRA score was seventeen (17), and on 10/23/12 at 3:42 PM it was seventeen (17), high risk.

Interview with NUC #3, on 10/26/12 at 3:45 PM, revealed there were eight (8) patients on the Stroke Unit that were high risk for falls on 10/23/12 at 5:50 PM. She agreed that Patient #16, #17, #18, #19, #20 and #21 did not have some interventions in place for high risk falls, such as bed and chair alarms. She stated these interventions should have been in place.

14. Observation of the Inpatient Pulmonary Unit, on 10/23/12 at 6:10 PM, revealed Patient #22 was lying in the bed in his/her room with no bed or chair alarm in use. Review of Patient #22's clinical record revealed he/she was admitted on 10/11/12 with diagnoses which included Bronchitis, Atrial Fibrillation, History of CVA and Generalized Weakness. The treatment plan included physical therapy and OT for pulmonary rehab and low dose Warfarin therapy. Admission FRA score was fifteen (15), and on 10/23/12 it was sixteen (16), high risk.

15. Observation of the Inpatient Pulmonary Unit, on 10/23/12 at 6:10 PM, revealed Patient #23 was lying in bed in his/her room without a bed or chair alarm in use. Review of Patient #23's clinical record revealed he/she was admitted on 10/12/12 with Diagnoses which included Acute Respiratory Failure, Atrial Fibrillation and Diabetes Mellitus, Type II. The treatment plan included physical therapy, OT and deep vein thrombosis prophylaxis with heparin. Admission FRA score was twenty (20), and on 10/23/12 at 5:58 PM it was twenty (20), high risk.

Interview with NUC #2, on 10/26/12 at 3:20 PM, revealed Patient #22 and #23 should have had bed and chair alarms in use. She further stated that use of these alarms made a difference in preventing falls and made patients feel more secure. NCU#2 further revealed facility staff did not correctly follow the facility's processes for fall prevention in the high fall risk patient.

The facility failed to provide a safe environment which placed patients at risk for injury, harm, impairment or death. On 10/24/12 Immediate Jeopardy was determined to exist.

The facility initiated corrective actions. These actions were as follows:

1. The NPC revised the Fall Risk Policy by adding a "Monitoring" section which required the NUC or designee to ensure audits are completed each shift for patients at high risk for fall. This was started on 10/25/12.

2. The NUC's created a "Rounding Log" for hourly rounding documentation to include assessment for pain, positioning, toileting, fluids/intake and environment. This log was to be posted in the patient room. This was started on 10/25/12.

3. The NUC's and House Administrators will round daily to ensure patients have bed and chair alarms in use. This was started on 10/25/12. The par level of chair alarms was increased to sixty (60) percent of average daily census. This was completed on 10/25/12.

4. The Pharmacy Director established a process for consultation on medications associated with high fall risk by placing a list of medications associated with high fall risk in the Medication Administration Record (MAR) section of the paper chart for all high risk patients. This was started 10/25/12.

5. The NUC's and House Administrators reviewed patient records to ensure all current high risk fall patients were provided education on equipment and fall prevention. This was completed 10/25/12.

6. The Nurse Educators began educating patient care staff on 10/25/12 on the Fall Prevention Process. Staff not available on 10/25/12 was notified to arrange for this education. It had to be done before staff was allowed to give patient care. This task is ongoing.

Interview with the NPC, on 10/26/12 at 5:45 PM, revealed approximately fifty (50) percent of employees had received this education. The plan was for the House Administrators or NUC's to give the education on 10/27/12 and 10/28/12 with the NUC's taking responsibility for the training on 10/29/12. Documents showed one hundred forty-three (143) staff members had received this education by exit on 10/26/12.

Interviews with ten (10) RN's, two (2) from each unit and the three (3) NUC's, on 10/26/12 from 3:00 PM to 5:30 PM, revealed all had received the education on the revised Fall Risk Policy on 10/25/12 or 10/26/12. They all stated they understood what interventions were required for all patients, either general or high fall risk, and had already implemented them.

7. The NUC's and House Administrators would begin auditing new forms and report results to the Chief Nursing Officer and Senior Management by shift, daily for the next fourteen (14) days. The results will also be reported to the Quarterly Quality Council. This began 10/25/12.

Observation of the Inpatient Pulmonary Unit, on 10/26/12 at 2:50 PM, revealed there were four (4) of sixteen (16) patients identified as high risk for falls. Two (2) of these four (4) patients were in therapy. The remaining two (2) were in wheelchairs. Both had chair alarms in use.

Observation of the Stroke Unit, on 10/26/12 at 3:35 PM, revealed there were sixteen (16) of twenty-six (26) patients that were high risk for falls. A sampling of five (5) of the sixteen (16) revealed all five (5) had bed and chair alarms in use.

Observation of the Brain Injury Unit, on 10/26/12 at 4:15 PM, revealed fourteen (14) of seventeen (17) patients were high risk for falls. Of these fourteen (14), a sampling of five (5) revealed one (1) had a one to one sitter and the others had bed and chair alarms in use.

Observation of the General Rehab Unit, on 10/26/12 at 5:00 PM, revealed ten (10) of twenty-three (23) patients were high risk for falls. Of these ten (10), a sampling of five (5) revealed all had bed and chair alarms in use.

Observation of the Spinal Cord Unit, on 10/23/12 at 5:20 PM, revealed there were twelve (12) of eighteen (18) patients that were high risk for falls. Of these twelve (12), a sampling of five (5) revealed two (2) were in bed with bed and chair alarms in use, and two (2) were in the unit dining room in wheelchairs with chair alarms in use.

The Immediate Jeopardy was determined to be abated on 10/26/12 prior to exit of the Survey on 10/26/12.

Based on observation, interview, record review and review of facility ' s policy, it was determined the facility failed to ensure nursing plans of care (POC) were properly implemented for fifteen (15) of twenty-three (23) sampled patients (Patient #5, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22 and #23). The facility failed to ensure the nursing staff were implementing interventions required by facility policy and Nursing POC for patients identified as high risk for falls.

The findings include:

Review of facility's policy, "Falls: Risk Assessment/Management," revised 09/2012, revealed the admitting Registered Nurse (RN) was responsible for ensuring the Fall Risk Assessment (FRA) was completed initially using the Fall Risk Assessment Tool approved at the Senior Management Meeting of 08/11/10. Then, every shift, or three times daily, it would be done again by the RN assigned to the patient to determine if there needed to be a reclassification of risk category, general risk or high risk. The Fall Risk Assessment Tool revealed there were seven (7) categories that were scored. These categories were 1) age; 2) fall history; 3) mobility; 4) elimination; 5) mental status change; 6) medications; and 7) client care equipment with tubing present. With this instrument, the higher the score, the greater the risk of a fall. The policy further revealed a score of fifteen (15) or above indicated a high risk and would trigger interventions to prevent falls from occurring. One of these high risk interventions was the use of bed and chair alarms.

Review of the facility's policy, "Nursing POC for Patients at High Risk for Falls", undated, revealed the interventions required for high risk fall patients were the same as those listed in facility's policy, "Falls: Risk Assessment/Management", revised 09/2012. the policy indicated for patients identified at high risk for falls were to have bed and chair alarms in place.

1. Review of the clinical record of Patient #5 revealed he/she was admitted on 09/26/12 with Diagnoses which included Cerebral Vascular Accident (CVA) with left sided hemiplegia. Treatment included physical therapy, occupational therapy and speech therapy daily. Medications included anticoagulation therapy of Enoxaparin 80 milligrams (mg) subcutaneously (SC) twice a day and Warfarin orally; the dose titrated to lab results that measured blood clotting time. The patient received seven (7) mg on 10/03/12. The physical therapy note of 10/04/12 at 8:40 AM revealed Patient #5 did not ambulate and required total assistance with the use of a wheelchair. Further review revealed the patient was identified as a high fall risk with a score of nineteen (19). Review of nurses ' notes from 10/04/12 and facility Occurrence Report No. 34154, dated 10/04/12, revealed Patient #5 fell from his/her wheelchair on 10/04/12 at 12:40 PM and sustained a laceration over the left eye with a large amount of swelling and bleeding. The Occurrence Report further revealed Patient #5 did not have a chair alarm on at the time of the fall. The record stated the patient was transferred to an acute care hospital emergency department (ED) for further evaluation. The record also revealed the Nursing POC for Patients with High Risk for Falls was in effect at the time of Patient #5's fall.

Review of the clinical record of Patient #5 from the acute care facility where the patient arrived on 10/04/12 at 2:08 PM via ambulance revealed the patient was oriented with a pain rating of five (5) on a zero (0) to ten (10) pain scale and a Glasgow Coma Scale (GCS; a score given to indicate neurological functioning; the lower the score, the more neurologically compromised) score of fifteen (15). Initial Computerized Tomography (CT) scan of the head showed a small parenchymal hemorrhage in the paramedian portion of the right posterior frontal lobe. A complete blood count (CBC) on 10/04/12 at 3:01 PM showed a platelet count of forty-four thousand (44,000) which is low. Two (2) units of Fresh Frozen Plasma (FFP) were ordered 10/04/12 at 3:59 PM, 7:58 PM and 10:18 PM. These six (6) units were given. Two units of Platelets were ordered on 10/04/12 at 5:28 PM and 11:49 PM. These four (4) units were given. Both FFP and Platelets are blood components given to aid in blood clotting. ED Hourly Rounding nurses' notes revealed no problems 10/04/12 at 9:00 PM; however, by 10:25 PM, Patient #5 had an altered mental status, was unable to follow commands, was disoriented and had a GCS score of nine (9). At 1:11 AM on 10/0/12, the notes reveal the patient continued to decline with labored breathing and a fixed pupil of four (4) millimeters (mm) in the right eye. The GCS score was six (6). Patient #5 was intubated and placed on a ventilator. CT scan of the head, on 10/05/12 at 4:44 AM, revealed progressive hemorrhages with active bleeding and a persistent subarachnoid hemorrhage. On 10/05/12 at 3:35 PM, Patient #5 was placed in an Intensive Care Unit (ICU) bed. On 10/15/12, the family of the patient decided to place the patient in a Do Not Resuscitate (DNR) status, and he/she was extubated. On 10/16/12, Patient #5 was discharged to a hospice unit with terminal diagnoses of subarachnoid hemorrhage and subdural hematoma due to a fall sustained at the facility on 10/04/12. Review of the hospice clinical record of Patient #5 revealed he/she expired on 10/19/12.

Interview with Physical Therapist #1, on 10/24/12 at 2:14 PM, revealed she discovered Patient #5, on 10/04/12 at 12:40 PM, face down on the floor. The patient was between the wheelchair and the bed, and the wheelchair was three (3) or four (4) feet from the bed. Physical Therapist #1 stated there was a lot of blood on the floor. She revealed six (6) people came into the room and lifted Patient #5 onto the bed. Physical Therapist #1 stated she left the room when Patient #5 had been lifted into the bed.

Interview with RN #1, on 10/24/12 at 1:40 PM, revealed she was Patient # ' s nurse on 10/14/12 at 12:40 PM when Patient #5 fell from her wheelchair. RN #1 stated Patient #5 had asked to go back to bed while sitting in her wheelchair. However, RN #1 revealed she delayed putting Patient #5 into bed at that time because it was time for his/her bolus nasogastric (NG) tube feeding and medications per NG tube were due. Therefore, she stated she believed it would be better for the patient to remain sitting up. RN #1 further revealed she then left Patient #5 ' s room for fifteen (15) to thirty (30) minutes to prepare the feeding and medications. She further stated Patient #5's seat belt was not fastened when he/she fell. Also, RN #1 stated Patient #5 did not have a chair alarm in use. She also stated she believed Patient #5 was safe to be in a wheelchair alone because the patient was not impulsive in her actions. RN #1 revealed she knew patients that were identified as a high fall risk should have bed and chair alarms in use.

Interview with Nursing Unit Coordinator (NUC) #1, on 10/24/12 at 4:10 PM, revealed Patient #5 was at high risk for falls, had a POC for being at high risk for falls that included the use of bed and chair alarms and should have had a bed and chair alarms in use but did not.

2. Review of the clinical record of Patient #10 revealed he/she was admitted on 08/11/12 with Diagnoses which included Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF) and Prostate Cancer. Treatment included daily physical therapy and occupational therapy for pulmonary rehab. FRA on 08/11/12 at 11:52 AM showed a score of seventeen (17), high risk. Rounding log on 08/11/12 at 10:00 AM, 11:00 AM and 12:00 PM showed neither the bed alarm nor chair alarm was being used. Physical therapy notes on 08/11/12 at 10:00 AM revealed Patient #10 ' s oxygen saturation level was between seventy-eight (78) and eighty-nine (89) percent on three (3) liters of oxygen delivered by nasal cannula. Patient #10's transfers from bed to wheelchair required moderate assistance of one (1). The physical therapy notes also state that Patient #10's medical condition had declined over the past two (2) days. Nursing progress notes, on 08/11/12 at 11:45 AM, revealed Patient #10 returned from Occupational Therapy (OT) and his oxygen saturation was ninety (90) percent on 2 liters of oxygen given by nasal cannula. The nurses' notes at 12:00 PM that day stated Patient #10 fell. The fall was also corroborated by Occurrence Report No. 34075, dated 08/11/12 at 12:00 PM. This report stated Patient #10 was found in his/her room, lying in the floor in front of the sink. He/she sustained a laceration to the upper lip with a minimal amount of bleeding. He/she also had a reddened area on the forehead. Patient #10 was sent to an acute care hospital ED for further evaluation. Review of the record also revealed the Nursing POC for Patients with High Risk for Falls was in effect at the time of Patient #10's fall.

Review of the clinical record of Patient #10 from the acute care facility where he/she was admitted on 08/11/12, revealed Patient #10 arrived at the facility via ambulance at 1:52 PM. CT scan of the head and facial bones while the patient was in the ED showed no acute changes. The two (2) centimeter (cm) laceration above the upper lip was repaired. Due to hypoxia (a partial pressure of oxygen of 32.7 on 2 liters of oxygen given by nasal cannula), the patient was admitted. The record revealed the admission was not due to injuries received during the fall at the facility. The record further revealed the patient underwent an aspiration of an abdominal lymph node which was consistent with metastatic adenocarcinoma. Aggressive therapy was not considered an option by the family; so, Patient #10 was discharged on 08/24/12 to home with a hospice consult.

Interview with RN #2, on 10/26/12 at 3:00 PM, revealed she had been caring for Patient #10 on 08/11/12 at 12 :00 PM when he/she fell. RN #2 stated she was making rounds and found Patient #10 lying in the floor in front of the sink. She stated she did not think Patient #10 had been identified or marked as a high fall risk. RN #2 further revealed she could not remember if Patient #10 had a bed or chair alarm in use, but she did not hear any alarm when the patient fell. She further indicated the intervention was on the patient's POC for the use of alarms as per the facility's policy.

Interview with NUC #2, on 10/26/12 at 3:20 PM, revealed she discovered Patient #10 did not have a chair alarm on when he/she fell. She further revealed had Patient #10 returned to the facility on 08/11/12 post-fall instead of being admitted to the acute care facility, she would have ensured Patient #10 had both a bed and chair alarm in use as required by the Fall Prevention Policy and the Nursing POC for Patients at High Risk for Falls.

3. Observation of the General Rehab Unit (GRU) on 10/23/12 at 4:40 PM, revealed Patient #11 was sitting up in a chair but did not have a chair alarm in use. Review of the clinical record of Patient #11 revealed he/she was admitted on 10/02/12 with Diagnoses which included a CVA and Insulin Dependent Diabetes Mellitus. The treatment plan included physical therapy, OT, and speech therapy (ST) daily. Patient #11 ' s initial FRA score was twenty (20), and on 10/23/12 at 4:46 PM the score was eighteen (18), high risk. Review of the record also revealed the Nursing POC for Patients at High Risk for Falls was in effect at the time of the above observation and indicated the patient should have had the bed and chair alarms in place.

4. Observation of the GRU, on 10/23/12 at 4:40 PM, revealed Patient #12 was sitting in a wheelchair but did not have a chair alarm in use. Review of the clinical record of Patient #12 revealed he/she was admitted on 10/13/12 with Diagnoses which included Brain Metastases (status post craniotomy) and Depression. His/her treatment plan included physical therapy and OT daily. Nurses' notes, on 10/13/12 at 11:07 PM, revealed a Certified Nurse Assistant (CNA) found Patient #12 on the floor scooting toward the bathroom. The patient stated he/she had the call bell on for fifteen (15) minutes. He slid himself to the floor, and he was not injured. The record revealed Patient #12's vital signs were within normal limits, and his Physician and family were notified of the fall. Patient #12's initial FRA score was fifteen (15), and on 10/23/12 at 4:00 PM it was seventeen (17), high risk. Additional review of Patient #12's record revealed the Nursing POC for Patients at High Risk for Falls was in effect at the time of the above observation and indicated bed and chair alarms should have been implemented for this patient.

5. Observation of the GRU, on 10/23/12 at 4:40 PM, revealed Patient #13 was lying in bed without a bed alarm in use. Review of Patient #13's clinical record revealed he/she was admitted on 10/20/12 with diagnoses which included a Ruptured Hepatic Cyst, Atrial Fibrillation (a heart arrhythmia) and General Debility. The treatment plan included physical therapy and OT daily. The initial FRA score was eighteen (18), and on 10/23/12 at 11:00 AM it was seventeen (17), high risk. Additional review of the record revealed the Nursing POC for Patients at High Risk for Falls was in effect at the time of the above observation, indicating the bed and chair alarm should have been implemented.

6. Observation of the GRU, on 10/23/12 at 4:40 PM, revealed Patient #14 was lying in bed with the bed alarm in use. However, there was no chair alarm being used when the patient got into the wheelchair. Review of the clinical record of Patient #14 revealed he/she was admitted on 10/13/12 with diagnoses which included a fractured left hip, status post surgical repair. Patient #14 had fallen at home which caused the fracture. He/she also had postop confusion and hyponatremia. The treatment plan included daily physical therapy, OT and ST. The admission FRA score was twenty-six (26), and on 10/23/12 at 3:57 PM it was twenty (20), high risk. The record further revealed the Nursing POC for Patients at High Risk for Falls was in effect at the time of the above observation, indicating Patient #14 should have had a bed and chair alarm in place as per the facility's policy.

7. Observation of the GRU, on 10/23/12 at 4:40 PM, revealed Patient #15 was sitting up in a chair eating. There was no chair alarm in use. Review of Patient #15's clinical record revealed he/she was admitted on 10/20/12 with diagnoses which included a CVA, Coronary Artery Disease (CAD), Hypertension and Atrial Fibrillation. The initial FRA score was nineteen (19), and on 10/23/12 at 4:00 PM it was twenty-four (24), high risk. Further review of the record revealed the Nursing POC for Patients at High Risk for Falls was in effect at the time of the above observation, indicating Patient #15 should have had a bed and chair alarm in place as per the facility's policy.

Interview with the Nurse Practice Coordinator (NPC), on 10/23/12 at 5:00 PM, revealed all high risk fall patients should have both a bed and a chair alarms in use. She further revealed if the patient was in bed and there was not a chair alarm in the pouch on the back of their wheelchair, the chair alarm was not being used. She confirmed interventions in the Nursing POC for Patients with High Risk for Falls were the same as those listed in the Falls Prevention Policy, and the facility should have been implementing both bed and chair alarms.

8. Interview with NUC #1, on 10/24/12 at 4:10 PM, revealed Patient #11, #12, #13, #14 and #15 were high risk for falls and did not have bed or chair alarms being used on 10/23/12 at 4:40 PM as required per facility policy and Nursing POC for Patients at High Risk for Falls.

9. Observation of the Stroke Unit, on 10/23/12 at 5:50 PM, revealed Patient #16 was lying in bed without a bed alarm or chair alarm in use. Review of the clinical record of Patient #16 revealed he/she was admitted on 10/18/12 with Diagnoses which included a CVA and CAD. The treatment plan included daily physical therapy, OT and ST. Admission FRA score was sixteen (16), and on 10/23/12 at 4:51 PM it was twenty-one (21), high risk. Further review of the record revealed Nursing POC for Patients at High Risk for Falls was in effect at the time of the above observation, indicating Patient #16 should have had a bed and chair alarm in place as per the facility's policy.

10. Observation of the Stroke Unit, on 10/23/12 at 5:50 PM, revealed Patient #17 was in the dining room on the unit in his/her wheelchair. There was not a chair alarm in use. Review of the clinical record of Patient #17 revealed he/she was admitted on 09/14/12 with Diagnoses which included a CVA and Insulin Dependent Diabetes Mellitus. Patient #17 was on Warfarin 1.5 mg daily. The treatment plan included daily physical therapy, OT and ST. Admission FRA score was nineteen (19), and on 10/23/12 at 9:00 AM it was eighteen (18), high risk. Additional review of the record revealed the Nursing POC for Patients at High Risk for Falls was in effect at the time of the above observation, indicating Patient #17 should have had a bed and chair alarm in place as per the facility's policy.

11. Observation of the Stroke Unit, on 10/23/12 at 5:50 AM, revealed Patient #18 was in a wheelchair in his/her room. There was not a chair alarm in use. Review of the clinical record of Patient #18 revealed he/she was admitted on 10/12/12 with Diagnoses which included Subarachnoid Hemorrhage and Subdural Hematoma, status post fall at home, and Hyponatremia. Patient #18 was on Enoxaparin 40 mg SC daily. The treatment plan included physical therapy, OT and ST daily. Admission FRA score was eighteen (18), and on 10/23/12 at 3:02 PM it was twenty-three (23), high risk. Further review of the record revealed the Nursing POC for Patients at High Risk for Falls was in effect at the time of the above observation, indicating Patient #18 should have had a bed and chair alarm in place as per the facility's policy.

12. Observation of the Stroke Unit, on 10/23/12 at 5:50 PM, revealed Patient #19 was lying in the bed in his/her room. There was no chair alarm in use. Review of the clinical record of Patient #19 revealed he/she was admitted on 10/18/12 with Diagnoses which included a CVA and Diabetes Mellitus, Type II. The treatment plan included physical therapy, OT and ST daily. Admission FRA score was sixteen (16), and on 10/23/12, it was twenty-four (24), high risk. Additional review of the record revealed the Nursing POC for Patients at High Risk for Falls was in effect at the time of the above observation, indicating Patient #19 should have had a bed and chair alarm in place as per the facility's policy.

13. Observation of the Stroke Unit, on 10/23/12 at 5:50 PM, revealed Patient #20 was lying in the bed in his/her room. There was no chair alarm in use. Review of Patient #20's clinical record revealed he/she was admitted on 10/18/12 with diagnoses which included a CVA and COPD. The treatment plan included daily physical therapy, OT, ST, and to continue Warfarin orally and low dose Enoxaparin SC. Admission FRA score was twenty (20), and on 10/23/12 at 2:44 PM it was twenty (20), high risk. Further review of the record revealed the Nursing POC for Patients at High Risk for Falls was in effect at the time of the above observation, which included the intervention for both bed and chair alarms.

14. Observation of the Stroke Unit, on 10/23/12 at 5:50 PM, revealed Patient #21 was lying in bed in his/her room. There was no chair alarm in use. Review of Patient #21's clinical record revealed he/she was admitted on 10/19/12 with Diagnoses which included a CVA and Atrial Fibrillation. The treatment plan included physical therapy, OT, ST and to continue long-term use of anticoagulants and low molecular weight heparin. Admission FRA score was seventeen (17), and on 10/23/12 at 3:42 PM it was seventeen (17), high risk. Additional review of the record revealed the Nursing POC for Patients at High Risk for Falls was in effect at the time of the above observation, which included the intervention for both bed and chair alarms.

Interview with NUC#3, on 10/26/12 at 3:45 PM, revealed there were eight (8) patients on the Stroke Unit that were high risk for falls on 10/23/12 at 5:50 PM. She agreed that Patient #16, #17, #18, #19, #20 and #21 did not have some interventions in place for high risk falls, such as bed and chair alarms. She stated these interventions should have been in place and were required by the Nursing POC for Patients at High Risk for Falls.

15. Observation of the Inpatient Pulmonary Unit, on 10/23/12 at 6:10 PM, revealed Patient #22 was lying in the bed in his/her room with no bed or chair alarm in use. Review of Patient #22's clinical record revealed he/she was admitted on 10/11/12 with Diagnoses which included Bronchitis, Atrial Fibrillation, History of CVA and Generalized Weakness. The treatment plan included physical therapy and OT for pulmonary rehab and low dose Warfarin therapy. Admission FRA score was fifteen (15), and on 10/23/12 it was sixteen (16), high risk. Further review of the record revealed the Nursing POC for Patients at High Risk for Falls was in effect at the time of the above observation, which included the intervention for both bed and chair alarms.

16. Observation of the Inpatient Pulmonary Unit, on 10/23/12 at 6:10 PM, revealed Patient #23 was lying in bed in his/her room without a bed or chair alarm in use. Review of Patient #22's clinical record revealed he/she was admitted on 10/12/12 with diagnoses which included Acute Respiratory Failure, Atrial Fibrillation and Diabetes Mellitus, Type II. The treatment plan included physical therapy, OT and deep vein thrombosis prophylaxis with heparin. Admission FRA score was twenty (20), and on 10/23/12 at 5:58 PM it was twenty (20), high risk. Further review of the record revealed the Nursing POC for Patients at High Risk for Falls was in effect at the time of the above observation, which included the intervention for both bed and chair alarms.

Interview with NUC #2, on 10/26/12 at 3:20 PM, revealed Patient #22 and #23 should have had bed and chair alarms in use. She further stated that use of these alarms made a difference in preventing falls and made patients feel more secure. NCU#2 further revealed facility staff did not correctly follow the facility ' s processes for fall prevention in the high fall risk patient, such as interventions listed in the Nursing POC for Patients at High Risk for Falls.

The facility failed to ensure that nursing staff developed, implemented and kept current, nursing care plans for each patient which placed patients at risk for injury, harm, impairment or death due to nursing interventions not being implemented according the Nursing POC for Patients at High Risk for Falls. On 10/24/12 Immediate Jeopardy was determined to exist.


The facility initiated corrective actions. These actions were as follows:

1. The NPC revised the Fall Risk Policy by adding a "Monitoring" section which required the NUC or designee to ensure audits are completed each shift for patients at high risk for falls. This was implemented on 10/25/12.

2. The NUC's created a "Rounding Log" for hourly rounding documentation to include assessment for pain, positioning, toileting, fluids/intake and environment. This log was to be posted in the patient room. This was started on 10/25/12.

3. The NUC's and House Administrators will round daily to ensure patients have bed and chair alarms in use. This was started on 10/25/12. The par level of chair alarms was increased to sixty (60) percent of average daily census. This was completed on 10/25/12.

4. The Pharmacy Director established a process for consultation on medications associated with high fall risk by placing a list of medications associated with high fall risk in the Medication Administration Record (MAR) section of the paper chart for all high risk patients. This was started 10/25/12.

5. The NUC's and House Administrators reviewed patient records to ensure all current high risk fall patients were provided education on equipment and fall prevention. This was completed 10/25/12.

6. The Nurse Educators began educating patient care staff on 10/25/12 on the Fall Prevention Process. Staff not available on 10/25/12 was notified to arrange for this education. It had to be done before staff was allowed to give patient care. This task is ongoing.

Interview with the NPC, on 10/26/12 at 5:45 PM, revealed approximately fifty (50) percent of employees had received this education. The plan was for the House Administrators or NUC's to give the education on 10/27/12 and 10/28/12 with the NUC's taking responsibility for the training on 10/29/12. Documents showed one hundred forty-three (143) staff members had received this education by exit on 10/26/12.

Interviews with ten (10) RN's, two (2) from each unit and the three (3) NUC's, on 10/26/12 from 3:00 PM to 5:30 PM, revealed all had received the education on the revised Fall Risk Policy on 10/25/12 or 10/26/12. They all stated they understood what interventions were required for all patients, either general or high fall risk, and had already implemented them.

7. The NUC's and House Administrators would begin auditing new forms and report results to the Chief Nursing Officer and Senior Management by shift, daily for the next fourteen (14) days. The results will also be reported to the Quarterly Quality Council. This began 10/25/12.

Observation of the Inpatient Pulmonary Unit, on 10/26/12 at 2:50 PM, revealed there were four (4) of sixteen (16) patients identified as high risk for falls. Two (2) of these four (4) patients were in therapy. The remaining two (2) were in wheelchairs. Both had chair alarms in use.

Observation of the Stroke Unit, on 10/26/12 at 3:35 PM, revealed there were sixteen (16) of twenty-six (26) patients that were high risk for falls. A sampling of five (5) of the sixteen (16) revealed all five (5) had bed and chair alarms in use.

Observation of the Brain Injury Unit, on 10/26/12 at 4:15 PM, revealed fourteen (14) of seventeen (17) patients were high risk for falls. Of these fourteen (14), a sampling of five (5) revealed one (1) had a one to one sitter and the others had bed and chair alarms in use.

Observation of the General Rehab Unit, on 10/26/12 at 5:00 PM, revealed ten (10) of twenty-three (23) patients were high risk for falls. Of these ten (10), a sampling of five (5) revealed all had bed and chair alarms in use.

Observation of the Spinal Cord Unit, on 10/23/12 at 5:20 PM, revealed there were twelve (12) of eighteen (18) patients that were high risk for falls. Of these twelve (12), a sampling of five (5) revealed two (2) were in bed with bed and chair alarms in use, and two (2) were in the unit dining room in wheelchairs with chair alarms in use.

The Immediate Jeopardy was determined to be abated on 10/26/12 prior to exit of the Survey on 10/26/12.