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Based on record review and interview, the facility failed to ensure the registered nurse provided adequate supervision of the patient's care. The deficient practice is evidenced by an incident involving a fall for 1 (#2) of 2 (#2, #3) reviewed patients assessed as high fall risk.
Findings:

Review of the policy "Falls Management," last revised 11/2021, revealed in part, "All patients will be assessed for risk of falling upon admission. Reassessments will be routinely performed to determine ongoing need for fall prevention precautions Any patients determined to be at risk for a fall will be placed on fall prevention measures. . . . E. Interventions related to transport of patient with High Fall Risk Score . . . 2. Transport with assistance of staff or trained caregivers when appropriate."

Review of the Nursing Flow sheet for Patient #2 revealed on 03/05/2024 at 1:28 p.m. a Morse Fall Risk Assessment was performed and the patient was given a score of 60 (high risk).

Review of the clinical notes from 03/05/2024 at 3:18 p.m. revealed "pt found on floor outside of restroom. Husband present at pts side. Walker in front of patient. Pt awake, alert and oriented x4. No loss of consciousness per pt. VS checked (see flowsheets). Huber needle with occlusive dressing found removed from patient's chest. VS re-assessed. Pts BP 174/94. Pt assisted into wheelchair by multiple RNs. Pt requesting to use the bathroom, pt assisted to bathroom by MA and RN X1. Pt returned to wheelchair. Charge Nurse, Sharon Welch, RN notified Cosgriff, MD of pt fall and VS taken after fall. MD informed pt received approximately half of Taxol infusion today and had not yet received her Carboplatin. Per MD, pt to be sent to Emergency Room. Pt and husband updated and verbalized understanding. ED triage nurse notified that pt will be brought to ER by Liz, RN. Pts port heparinized and pt brought to Emergency Room via wheelchair."

In interview on 03/25/2024 at 1:05 p.m., S5MOPI verified Patient #2 was evaluated as a high fall risk and required the assistance of a walker. S5MOPI verified nursing staff should have assisted the patient to the restroom accompanied by the patient's husband, even if Patient #2 insisted she only needed the husband's help.

In interview on 03/25/2024 at 3:30 p.m., S2SDQ and SDQ3 also verified the nurse should have accompanied the patient to the restroom to ensure her safety while receiving the infusion.