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Based on interview, record review, and review of the facility's policy, it was determined the facility failed to provide care and services for one (1) of ten (10) sampled patients (Patient #1) in accordance with facility policies. According to the facility's care planning policy, the Registered Nurse (RN) was required to assess each patient and develop a plan of care to facilitate the achievement of patient goals. The facility assessed Patient #1 and determined the patient was at high risk for falls. However, interview with staff and review of the patient's medical record revealed the facility failed to ensure an "exiting alarm" (an exiting alarm or bed alarm sounds when a patient gets out of bed to alert staff that the patient is out of bed unassisted) was being utilized for the patient as required by the facility's Fall Prevention Policy. On 06/29/19 at 10:45 PM, Patient #1 got out of bed without staff knowledge and fell, resulting in a pelvic fracture.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure services were furnished in accordance with appropriate written policies and procedures. The facility failed to implement their grievance policy, including ensuring a prompt resolution of a grievance for one (1) of ten (10) sampled patients (Patient #1). On 07/01/19, Patient #1's Family Member contacted the facility to "report" that he had walked into the patient's room and observed a staff member attempting to forcibly take Patient #1's purse from him/her. However, Unit Manager #1, who spoke to the family member, failed to follow the facility's policies and procedures regarding complaints and grievances, and the facility took no action to ensure the grievance was resolved.

The findings include:

Review of the facility's policy titled "Procedure for Handling Patient Complaints and Grievances," revised March 2019, defined a complaint as any concern received by a patient or family member of a patient who was still admitted to the facility. Further review of the policy revealed if the concern warranted further exploration or discussion, the concern would be discussed with the Grievance Committee or other designated group. Further review of the policy revealed complaints, compliments, and grievances are maintained by the facility Patient Affairs Representative, where documentation and feedback are archived to ensure each issue is resolved.

Review of Patient #1's medical record revealed the facility admitted the patient on 06/27/19 with diagnoses of Severe Edema, Status Post Right Hip Fracture, and Chronic Lumbago.

Interview with Patient #1 on 07/10/19 at 11:25 AM revealed two (2) staff members came into the patient's room (unable to recall exact date) and observed Patient #1 self-administering medication from his/her purse. Patient #1 stated, "They said let me see your purse, and I said no. I told them it was a stomach pill and I even offered to give them one of the pills. The younger staff woman kept insisting and saying let me see what is in your purse. I told her no again, and then she grabbed my purse right out of my hands and I grabbed it back. She did look inside my purse though, and it really surprised me how she acted; it made me mad."

Interview with Patient #1's Family Member (Family Member #2) on 07/09/19 at 2:30 PM, revealed he called the facility on 07/01/19, and spoke to Nurse Manager #1. Family Member #2 stated he told Nurse Manager #1 that he wanted to "report" that on 07/01/19, sometime after lunch, he had walked into the patient's room and a staff member was trying to take Patient #1's purse away from him/her. Family Member #2 stated Patient #1's purse was in his/her lap, and they were having a "tug of war with the purse." Family Member #2 stated Patient #1 was yelling at the staff "you cannot have my purse." Family Member #2 stated it made him "very mad" and he told the staff pulling on Patient #1's purse that she had no business trying to take Patient #1's purse away from him/her. Family Member #2 stated no one from the facility has ever contacted him about the reported concern.

Interview with Nurse Manager #1 on 07/10/19 at 1:27 PM revealed she did talk to Family Member #2 on 07/01/19, when he called the facility. Nurse Manager #1 stated Family Member #2 wanted to "report" that he had walked into Patient #1's room and observed staff trying to pull the patient's purse away from him/her. Nurse Manager #1 stated she could not recall if she informed the family member that the patient had been found self-administering medications from his/her purse. Nurse Manager #1 stated the reason they were attempting to obtain the patient's purse was to find out what medications the patient had in the purse. The Unit Manager stated, "I did not fill out an incident report and I did not treat this like a grievance because I felt like I was forthcoming to him. I can't remember when he called and I did not document any of it."

Interview with the Director of Nursing (DON) on 07/10/19 at 8:25 PM revealed when the family member stated he wanted to report something to Nurse Manager #1, the Nurse Manager should have documented the conversation, and should have directed the family member to the Complaints Intake, Risk Manager, or the DON. The DON stated the facility's complaint and grievance procedures should have been implemented.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure nursing staff supervised the nursing care for one (1) of ten (10) sampled patients (Patient #1). The facility assessed Patient #1 to be at high risk for falls and documented that interventions, which included a bed alarm (sounds when the patient gets out of bed), were in place due to the high fall risk on 06/29/19 at 9:22 PM. However, on 06/29/19 at 10:45 PM, the facility failed to ensure Patient #1's bed alarm was being utilized. Patient #1 got out of bed and attempted to walk to the bathroom on his/her own without staff assistance or the patient's walker. The patient fell and sustained a left-sided pelvic fracture.

The findings include:

Review of a facility policy titled "Fall Prevention," revised September 2016, revealed the scope/purpose was to improve patient safety by identifying patients at risk for injury from a fall; to systematically assess risk factors for injury; to provide guidelines for injury risk and fall preventive interventions; and to outline procedures for documentation and communication; thereby lowering the patient risk and risk of a fall. The policy further revealed to implement moderate to high fall risk prevention interventions for scores of twenty-five (25) and above as appropriate and/or additional intrinsic and extrinsic factors. The interventions were to include an "Exiting Alarm" (bed alarm) on patients that were assessed to be at high risk for falls.

Review of Patient #1's medical record revealed the facility admitted the patient on 06/27/19 with diagnoses of Severe Edema, Status Post Right Hip Fracture, and Chronic Lumbago.

Review of Patient #1's care plan dated 06/28/19, revealed the patient was at risk for falls related to a history of falls, impaired judgement/lack of safety awareness, agitation, impaired gait, shuffle/wide base, unsteady walk, dizziness, vertigo, or treatment circumstances. The care plan further revealed Patient #1 would be safeguarded from falls and associated injuries.

Review of the nurse's notes on 06/29/19 at 9:22 PM, revealed Registered Nurse (RN) #3 had assessed Patient #1's fall risk and documented that the patient was at high risk for falls and that high risk interventions were in place.

However, a review of an incident report dated 07/01/19, revealed on 06/29/19 at 10:45 PM, staff heard Patient #1 call out from his/her room and staff found the patient on the floor. Further review of the incident report revealed staff assessed Patient #1 for signs/symptoms of injury, assisted the patient back to bed, and "Bed Alarm turned on." According to the incident report, Patient #1 sustained a fracture of the pelvis as a result of the fall.

Interview with Patient #1 on 07/10/19 at 11:25 AM revealed on the night of 06/29/19 he/she had to go to the bathroom; however, his/her walker and bedside commode (BSC) were on the other side of the room. Patient #1 stated he/she rang his/her call light several times and when staff did not respond, he/she tried to ambulate without assistance, and fell.

Interview with State Registered Nurse Aide (SRNA) #1 on 07/10/19 at 4:40 PM revealed before Patient #1 fell on 06/29/19, his/her call light had not been activated and was off prior to the fall. SRNA #1 stated RN #3, RN #6, and she found Patient #1 on the floor, on his/her bottom, with his/her legs straight out in front of him/her.

Interview with Registered Nurse (RN) #3 on 07/10/19 at 5:35 PM, revealed on 06/29/19 staff heard Patient #1 yelling for help. She stated she went to Patient #1's room, along with RN #3 and RN #6, and found the patient sitting on the floor. RN #3 revealed Patient #1's call light had not been activated before the fall. RN #3 further revealed that after Patient #1's fall, she turned on the patient's bed alarm. She further stated, "The patient's bed alarm was not on prior to the fall because during an assessment the patient revealed [he/she] would not get out of the bed."

Interview with RN #6 on 07/10/19 at 5:05 PM, revealed on 06/29/19 she heard Patient #1 yelling for help from his/her room. She stated they found Patient #1 was sitting on his/her bottom, with his/her legs straight out. RN #6 revealed Patient #1 denied injury and staff assisted the patient back to bed. RN #6 further revealed the patient had not activated the call light prior to the fall, and the patient's bed alarm was not on prior to the fall.

Interview with the Director of Nursing (DON) on 07/10/19 at 8:25 PM revealed when an assessment determined that a patient was at high risk for falls, the bed alarm should be on at all times. She stated staff were taught that some of the fall interventions were subject to assessment; for example, bed in low position, one to one supervision, or an arm bracelet. However, the DON stated bed alarms were not optional and should be on at all times if the patient was at high risk for falls.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develop a nursing care plan for one (1) of ten (10) sampled patients (Patient #1), in accordance with facility policy. The facility assessed Patient #1 and determined the patient was at high risk for falls. However, the facility failed to ensure an "exiting alarm" (an exiting alarm or bed alarm sounds when a patient gets out of bed to alert staff that the patient is out of bed unassisted) was being utilized for the patient. On 06/29/19 at 10:45 PM, Patient #1 got out of bed without staff knowledge and fell, resulting in a pelvic fracture.

The findings include:

Review of the facility policy titled "Patient Plan of Care," with a revision date of January 2017, revealed each patient's plan of care was based on the prioritization of patient care needs identified through analyzing data obtained from the admission history and nursing assessment during the initial assessment, and revised as indicated by subsequent assessment/observations and changes in the patient's condition. The policy further revealed the Registered Nurse (RN) was responsible for the identification of nursing interventions that would facilitate the achievement of the specific goals for the patient.

Review of a facility policy titled "Fall Prevention," revised September 2016, revealed patients that were assessed to be at high risk for falls should have care plan interventions that included an "Exiting Alarm."

Review of Patient #1's medical record revealed the facility admitted the patient on 06/27/19 with diagnoses of Severe Edema, Status Post Right Hip Fracture, and Chronic Lumbago.

Review of Patient #1's Nurse's Notes dated 06/29/19 at 9:22 PM, revealed staff assessed Patient #1's fall risk, determined the patient was at high risk for falls, and documented that high risk fall interventions were in place.

However, a review of Patient #1's care plan dated 06/28/19, revealed that even though the facility determined the patient was at risk for falls related to a history of falls, impaired judgement/lack of safety awareness, agitation, impaired gait, shuffle/wide base, unsteady walk, dizziness, vertigo, and treatment circumstances, and documented that Patient #1 would be safeguarded from falls and associated injuries, there was no documented evidence that the facility developed an intervention for an "exiting alarm" as required by the facility's policy.

Review of the incident report dated 07/01/19, revealed on 06/29/19 at 10:45 PM, Patient #1 sustained a fall and there was no documented evidence that the patient's exiting/bed alarm was implemented prior to the fall. According to the incident report, the bed alarm was "turned back on."

Interview with RN #6 on 07/10/19 at 5:05 PM, revealed on 06/29/19 prior to Patient #1's fall, the bed alarm was not turned on.

Interview with RN #3 on 07/10/19 at 5:35 PM, regarding Patient #1 revealed, "The patient's bed alarm was not on prior to the fall because during an assessment the patient revealed [he/she] would not get out of the bed."

Interview with RN #5 on 07/10/19 at 7:55 PM, revealed not all patients who were at risk for falls required a bed alarm and the nurse could decide if a patient needed a bed alarm.

However, an interview with the Director of Nursing (DON) on 07/10/19 at 8:25 PM revealed when a patient was assessed to be at high risk for falls, the bed alarm should be on at all times. She some fall interventions were subject to the nurse's assessment; however, bed alarms were not subject to assessment.