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Based on observation of the facility's video, interview, record review and review of the facility's incident report and falls protocol, it was determined the facility failed to ensure the Registered Nurse (RN) evaluated one (1) of ten (10) sampled patients (Patient #1). The facility failed to follow accepted standards of nursing practice and hospital protocol after Patient #1 experienced a fall and was not evaluated per the Falls Protocol, no Falls Assessment Tool was completed and there was no documentation on the progress notes that the fall had occurred.

The findings include:

Interview with the Risk Manager, on 07/19/12 at 10:30 AM, revealed when there was a fall, an incident report and the falls protocol should be followed. The Risk Manager continued by saying the falls protocol informed the staff each step which should be taken.

Review of the Falls Protocol, undated, revealed the RN must assess the patient using the Falls Assessment Tool and place in the patient's record, also document incident and assessment in the patient's record and Cardex and alert the Physician if a patient had received a PRN (as needed) medication in the last twenty-four (24) hours.

Review of the facility's Incident Report completed by RN #2, dated 07/14/12 (even though the incident occurred on 07/15/12), revealed Patient #1 was agitated and striking out at staff when he/she threw self into the laundry basket then onto the floor landing on his/her abdomen.

Interview with RN #2, on 07/23/12 at 11:00 AM, revealed Patient #1 had hit staff members and also threatened staff on 07/15/12. RN #2 stated she believed Patient #1 had fallen purposefully. RN #2 stated she did fill out the incident report and opened a Falls focus area in Patient #1's Personal Recovery Plan, but did not followed the Falls Protocol. RN #2 stated she was not aware there was a Fall Assessment Tool and did not notify the Physician because RN #2 stated there was no injury. RN #2 stated she should have documented the fall in Patient #1's clinical record.

Observation of the facility's video recording of the incident involving Patient #1 on 07/15/12, revealed Patient #1 accidentally tripped and fell over the laundry cart.

Review of the Admission History revealed Patient #1 was admitted 02/15/12 with diagnoses which included Impulse Control Disorder, History of Bipolar Disorder and Mild Mental Retardation.

Review of the wittness statement, dated 07/17/12 and confirmation through interview with Mental Health Associate (MHA) #1, on 07/19/12 at 3:00 PM, revealed Patient #1 tripped on his/her shoes and fell over the laundry cart.

Interview with the Charge Nurse, on 07/18/12 at 12:15 PM, revealed Patient #1 had fallen on 07/15/12 at 7:30 PM. He stated he was not sure if Patient #1 had tripped or if Patient #1 had thrown self to the floor. The Charge Nurse stated it was not necessary to notify Patient #1's Physician.

Interview with Licensed Practical Nurse (LPN) #1, on 07/19/12 at 3:15 PM, revealed she had not seen the fall, but when she heard the crash, she rushed out of the medication room and saw Patient #1 lying on the floor flat with her foot wrapped around the wheel of the laundry cart. LPN #1 stated she had given Patient #1 a PRN, Haldol five (5) milligrams (mg), Benadryl 50 mg and Ativan 2 mg on 07/15/12, at 7:25 PM.

Review of the "PRN Interventions and Medication Administration Record" revealed Patient #1 had been given the same PRN medications on 07/14/12 at 10:45 PM.

Interview with the Director of Patient Care Services/Director of Nursing, on 07/23/12 at 1:30 PM, revealed when a patient fell, staff was to fill out an incident report and follow the Falls Protocol, even if the patient had fallen intentionally or accidentally. She further stated the Falls Protocol instructed on each step which needed to be followed and Patient #1 should have been assessed and the Physician notified after the fall on 07/15/12 as per the facility's protocol.