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Based on observation, interview, and record review the facility failed to meet the Condition of Participation for Patient Rights by failing to protect the rights of 2 of 5 patients (#1, #5) requiring a safe environment resulting in the potential for all current and future patients being at risk for loss of their rights. Findings include:

1. Based on observation, interview, and record review the facility failed to provide a safe environment for 2 of 5 patients (#1, #5) at risk for falls resulting in patient #1 falling during a transfer incurring a hip fracture, and Pt #5 not wearing an appropriate armband signifying high risk for falls. (See A-144).

Based on observation, interview, and record review the facility failed to provide a safe environment for 2 of 5 patients (#1, #5) at risk for falls resulting in patient #1 falling during a transfer incurring a hip fracture, and Pt #5 not wearing an appropriate armband signifying high risk for falls. Findings include:

Patient (Pt) #1.

Review of the assessment and evaluation flowsheet dated 05/04/20 at 0820 indicated Pt #1 was a 72 year old male assessed as being a high risk to fall based on a total fall risk score of 13. This flowsheet also indicated Pt #1 had a "Get-Up-And-Go" (a component of the fall risk assessment) score of 4 based on multiple attempts or loss of balance.

Review of incident report last dated 05/14/20 indicated on 05/04/20 at 0940 Patient (Pt) #1 returned from an x-ray and while being assisted back into the bed by the transporter (Staff D), Pt #1 "pulled himself to the right, causing him to fall.". The incident report indicated it was a "Witnessed fall resulting in injury-intertrochanteric right hip fracture, which required surgery.". The report also indicated Staff D "was assisting patient back to bed from stretcher when the patient suddenly pulled away to the right" and "immediately fell down on his right side ...The patient states his IV pole rolled out fast, causing him to fall. The transporter states the patient pulled away from her and she tried to catch him, but was unsuccessful." The report also indicated Pt #1 had a fall risk level score of 13 (high risk to fall). The report did not provide any detail regarding the use of any gait belts or other assistive devices during the transfer.

Review of x-ray diagnostic reports dated 05/04/20 at 1237 and 05/04/20 at 1251 indicated Pt #1 had trauma which resulted in an intertrochanteric right hip fracture.

Review of the Fall Prevention Audit Tool dated 05/04/20 at 2030 indicated, under question 11, "What could have been done to prevent the fall? (nurse/manager assessment)", the answer was documented as "Assist pt from stretcher to bed. Help push his IV pole. Ask CNA/RN to help.".

During an interview with the Director of Intensive Care (RN H) on 08/09/21 at 1445, RN H said she could find no evidence that Staff D used a gait belt or other assistive devices during the transfer of Pt #1 on 05/04/20 that resulted in a fall with injury.

During interviews with the Regulatory Compliance Manager (Staff B) on 08/09/21 at 1415 and 08/10/21 at 0940, Staff B said, on 05/04/20 prior to the fall, Pt #1 had a "Get-Up-And-Go" score of 4 and was considered a high risk to fall based on a total fall risk score of 13. Staff B said a "Daily Passport" form was used by transport staff to identify specific needs of the patient to ensure safe transport and handover. Staff B said the facility was unable to provide a copy of the "Daily Passport" form for Pt #1's transfer occurring on 05/04/20 because the form was not a permanent part of the medical record. Staff B said the only known witness to the fall was the transporter (Staff D) who no longer worked at the facility.

On 08/10/21 at 1545 Staff D was unable to be contacted via phone number provided by the facility. Review of Staff D's personnel record revealed Staff D left the facility voluntarily on 06/26/20.

Patient (Pt) #5.

During tour of the facility and interviews with RN K on 08/09/21 at 1225, with RN E and RN N present, Pt #5 was observed lying in bed wearing a red armband on the left wrist. RN K was queried as to the purpose of the red colored band. RN K indicated 'that's an allergy band.' RN K was then queried, "How would staff know if this patient was at risk for falls?". RN K looked at Pt #5 who was wearing a red (allergy) and white (patient ID) band, turned and removed a plastic bin from beneath the counter. This container contained various colored bands visible through the container, from which RN K pulled out two. RN K stated, "these are the new fall bands, but I think we're using up all the old ones first'. Based on this observation, Pt #5 was not wearing any armband identifying her as a fall risk.

A review of Pt #5's fall score documentation was completed on 08/09/21 at 1510. Based on this review Pt #5 was assessed as being a high risk to fall on 08/09/21 at 0930 with a fall risk score of 95. This was the most recent fall risk assessment completed prior to the observations made during facility tour on 08/09/21 at 1225.

Review of emergency room and admission assessment documentation beginning 08/04/21 revealed Pt #5 was a 78 year old female with history of diabetes, hypertension, peripheral artery disease, status post left below the knee amputation, chronic kidney disease, atrial fibrillation, and chronic obstructive pulmonary disease. Pt #5 presented to the hospital emergency room with complaint of fall and altered mental status at home. The record indicated Pt #5 had been having more frequent falls secondary to weakness.

Review of facility policy and procedure titled, "Inpatient Fall Prevention and Post Fall Procedure", approved July 2019 and expiring July 2022 indicated, under "Procedure" section, "d) A fall risk bracelet consistent with the patient's risk level will be applied to the patient." and "e) The patient's environment is assessed to see if there are any hazards that may increase the chance of the patient falling or causing injury to himself/herself." Within this policy and procedure there was an attachment labeled, "Fall Risk Interventions High Risk Patient Cognitively Alert Risk Score > (or equal to) 4" that indicated, under "Get-up-and-go (TUG)" section, that a patient having a get-up-and-go score of 4 would require "Assist with transfers and use gait belt or device".

Review of additional facility procedure titled, "Fall Prevention Procedure", approved August 2021 indicated, under section "Universal Fall Prevention Procedures", "All HIGH fall risk patient should have a yellow fall arm bracelet", and under section "Use of Alarm and Avasys", "Use gait belts with all patients using assistive devices or with unsteady gait.".

Review of facility policy titled, "Transporting Patients--General Information", approved January 2020, indicated within section 3, " ...Passport to Radiology will be used to communicate patient specific needs.".