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Based on medical record review and interview, the hospital did not ensure a safe environment for Patient #1 who had been assessed as being at a high risk for fall.

Findings include:

Review of the Plan of Care for the Patient Problem: Fall Risk dated from 12/01/13 through 12/20/13 indicated the patient had been identified as a fall risk. Patients identified as being at risk for fall are provided with a yellow blanket and yellow non-skid socks.

Interview on 3/17/14, with Staff #24, Facility Volunteer, revealed the patient was transported from physical therapy to her room via wheelchair on 12/19/13. Following arrival, the patient was left in the wheelchair, next to her bed with her call light and the over-the-bed table over her lap. The patient's personal alarm (a flat piece of plastic/vinyl that is placed behind a patient ' s shoulder while the patient is in a chair. The alarm is attached to a cord that clips onto the patient ' s shoulder (over clothes) with an " alligator " clip. Between the cord and the plastic pad are magnets that, if disconnected, will sound an alarm) was not checked as it was covered by a yellow blanket. Nursing staff were not informed that the patient had been returned to the unit.

Interview with Staff #18, on 3/07/14 at 3:20PM, revealed that the patient was observed ambulating in the hallway, without assistance, at approximately 12:00PM. The patient " appeared to stumble and fall forward " , hitting her head. The bathroom call light over the patient room doorway was noted to be flashing. A Rapid Response was called and the patient was transported to the Emergency Department (ED).