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Based on review of facility policy, medical record review, review of facility documentation and interview, the facility failed to ensure education and training was completed related to falls prevention for 1 patient (Patient #3) who suffered a fall of 3 patients reviewed.

The findings include:

Review of facility policy, "Fall Management Program" revised 11/20/24, showed "...Post Fall Management for all patients: Complete an initial post fall assessment, including documentation of neurological checks and vital signs, and then repeat assessment (including neuro checks and vital signs) every 30 minutes x (times) 2. Perform additional neurological assessments every 1 hour x4 for patients who it is determined if they hit their head during fall (i.e. unwitnessed fall and patient confused or unable to recall if they hit their head)..."

Medical record review showed Patient #3 was admitted on 8/20/2025 with diagnoses including Altered Mental Status, Urinary Tract Infection (UTI) and Acute Encephalopathy (confusion, memory loss and personality changes). The patient had a documented Do Not Resuscitate (DNR). The patient had previous history of Alzheimer's Disease, Dementia, Severe Protein Malnutrition, recurrent UTI, an Indwelling urinary catheter, and decubitus ulcer. The patient was placed on the fall preventions protocol.

Medical record review of a Nurses Note dated 8/22/2025 at 1:00 AM showed the patient suffered an unwitnessed fall on 8/22/2025 at 12:00 AM where she was found unresponsive and had an acute mental status change from her baseline. There was "...facial symmetry drooping right side of mouth..." The patient was assisted back to the bed. The Hospitalist was notified, and a Computed Tomography (CT) of the brain was ordered and completed.

Medical record review of a Hospitalist Progress Note dated 8/22/2025 at 5:57 AM showed the patient's CT revealed a minimal supratentorial subarachnoid (bleeding between the brain and the tissues) and subdural bleed (brain bleed). The patient's assessment showed "...pupils dilated, round, nonreactive to light and accommodation. Respiratory: Clear to auscultation bilaterally, unlabored breathing... Neurologic: GCS (Glasgow Coma Scale) 5, mouth deviation..." Multiple attempts were made to get the patient transferred to a higher level of care. The patient's vital signs remained stable but continued with an acute mental status change. The patient was transferred to a Level 1 Trauma Center on 8/22/2025.

Review of facility education training showed reeducation for the Fall's Protocol was implemented on 8/22/2025 for nursing care staff members. On the telemetry unit (the unit where the fall occurred) 35 of 38 (92%) of the staff had completed the training and 2 out of the 35 employees were full-time and had not completed the training. Review showed in the Intensive Care Unit (ICU) only 48 of 53 (90%) of the staff had completed the training and in the Emergency Department 40 of 43 (93%) of the staff had completed the training. Further review showed only 93% of the staff had completed the training as of 11/4/2025 (2 months and 12 days after the education was implemented).

During an interview on 11/4/2025 at 9:30 AM, the Risk Manager stated education was implemented related to an increased number of falls in the facility. The education was not related specifically to Patient #3's fall. She confirmed the education was started on 8/22/2025 and all nursing care providers had not completed the training.