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Based on interview and record review, the facility failed to establish an individualized plan of care, failed to ensure nursing and support staff adhered to the policies and procedures of the facility, and failed to ensure that nursing documented fall risk assessments accurately.

See tags:
A0396 - Nursing Care Plan
A0398 - Supervision of Nursing Personnel

Based on interview and record review, the facility failed to establish an individualized plan of care for 1 (P-1) of 10 patients reviewed, resulting in the potential for unmet care needs and negative outcomes for this patient. Findings include:

P-1 is a 67-year-old male with a past medical history of cerebral vascular accident with residual left side weakness, coronary artery disease, chest pain/angina, diabetes mellitus, reflux, hyperlipidemia, hypertension, myocardial infarction, osteoarthritis, and prostate disorder. On 7/1/25, P-1 underwent ureteroscopy with kidney stone lithotripsy and bilateral renal stent placement. P-1 presented to the emergency center (EC) on 7/8/25 with sepsis with leukocytosis, fever, and possible urinary tract infection. On 7/9/25 at 1030, P-1 had an unwitnessed fall while in the EC, fracturing his left proximal humerus as well as an acute mildly displaced left proximal femur sub capital neck fracture. On 7/11/25, a left direct anterior hip hemiarthroplasty was performed. P-1 was transferred to an extended care facility on 7/17/25.

During record review on 9/2/25, it was noted that the plan of care initiated on 7/8/25 included discharge planning, knowledge deficit, pain management, and safety/protection. The plan failed to include fall risk or sepsis. This finding was reviewed and acknowledged with the Director of Quality (Staff C) on 9/2/25 at 1300.

Based on record review and interview, the facility failed to ensure nursing and support staff adhered to the policies and procedures of the facility and failed to ensure that nursing documented fall risk assessments accurately in 1 (P-1) of 10 records reviewed, resulting in an unwitnessed fall and the patient sustaining two fractures. Findings include:

P-1 is a 67-year-old male with a past medical history of cerebral vascular accident with residual left side weakness, coronary artery disease, chest pain/angina, diabetes mellitus, reflux, hyperlipidemia, hypertension, myocardial infarction, osteoarthritis, and prostate disorder. On 7/1/25, P-1 underwent ureteroscopy with kidney stone lithotripsy and bilateral renal stent placement. P-1 presented to the emergency center (EC) on 7/8/25 with sepsis with leukocytosis, fever, and possible urinary tract infection. On 7/9/25 at 1030, P-1 had an unwitnessed fall while in the EC, fracturing his left proximal humerus as well as an acute mildly displaced left proximal femur sub capital neck fracture. On 7/11/25, a left direct anterior hip hemiarthroplasty was performed. P-1 was transferred to an extended care facility on 7/17/25.

The fall risk assessment tool was completed on 7/8/25 at 1800 and evaluated the following: age (60-69; 1 point), fall history (N/A), elimination, bowel and urine (N/A), Medications (on 1 or more fall risk drug; 3 points), Patient Care Equipment (IV infusion; 1 point), Mobility (requires assistance or supervision for mobility, transfer, or ambulation; 2 points), and Cognition (N/A). P-1's initial fall risk score was 7, which indicates a moderate fall risk (6-13 points). The chart review indicated that P-1 was incontinent of urine and presented to the EC with urinary tract infection symptoms. These findings were not included in the fall risk assessment and have the potential to add an additional 2 points for incontinence or 4 points for urgency/frequency and incontinence. Medication review indicates that P-1 was taking Trazadone 50mg at night, Neurontin 300mg at night, Ultram 50mg, four times a day as needed, and Dilaudid 0.5mg, that was given 7/8/25 at 1039, patients on 2 or more high fall risk drugs receive 5 points. The chart review also indicated the patient has left side weakness from prior stroke, ambulates with a walker and was brought to the EC with increased weakness. Unsteady gait would add 2 additional points, for a fall risk score of 13 to 15 points. Fall risk scores greater than 14 are high risk.

Review of the Fall Prevention Guidelines indicate that patients with moderate and high-risk are identified with yellow armband and yellow socks, document risk on whiteboard, and include risk in handoff. Patients with moderate risk should be supervised with bedside activities and those at high-risk interventions include supervising all ambulating, and 1:1 toileting.

EC Tech (Staff M) was interviewed on 9/3/25 at 0937. Staff M stated that on 7/9/25, he was working as a float throughout the EC. He went into P-1's treatment room to help him up to the commode. Staff M stated that when the patient was done, he stood him up and then sat him back down on the commode and went out of the room to find assistance to get him back into bed, and that is when he heard him fall. When queried about the fall risk precautions that were in place, Staff M stated that P-1 didn't have a fall risk bracelet on at that time, and he couldn't recall if he had yellow socks on or if fall risk was written on the whiteboard in the room. When queried about the handoff communication, Staff M stated, "I didn't get a report on this patient."

Policy- Fall Prevention Guidelines (1.2.7, revised 10/22) states for moderate risk (score 6-13) : yellow armband and yellow socks are applied, document risk on whiteboard, include risk in handoff, remove clutter, ensure adequate lighting, keep clear path to bathroom, coil/secure excess cords, supervise bedside activities, orient patient to surroundings, education on fall risk, establish elimination schedule, encourage call light use, answer call light promptly, purposeful hourly rounds, activate bed and chair alarms, and consider adding Virtual Safety Companion. For high risk (scores above 14) includes moderate interventions and in addition includes supervise all ambulating, use gait belt during ambulation, and 1:1 toileting.