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Based on document review and staff interview, the acute care hospital's administrative staff failed to ensure the behavioral health nursing staff adequately assessed for the presence of pain or injury and obtain timely interventions for 1 of 1 patient (Patient #1) who sustained a fall with injury while an inpatient on the geriatric behavioral health unit. Please refer to A-0935 for additional information.


The cumulative effect of these failures and deficient practices resulted in the hospital staff's inability to ensure patients received safe nursing services.

Based on document review and staff interviews, the acute care hospital administrative staff failed to ensure the behavioral health nursing staff adequately assessed for the presence of pain or injury and obtain timely interventions for 1 of 1 patients (Patient #1) who sustained a fall with injury while an inpatient on the geriatric behavioral health unit. Failure to adequately assess for the presence of pain or injury resulted in Patient #1 waiting approximately 57 hours before undergoing surgery to repair a broken left hip suffered during a fall in the geriatric behavioral health unit. The hospital staff identified an average daily census of 524 patients for the hospital, and an average daily census of 44 patients for the Behavioral Health unit.

Findings include:

1. Review of the procedure "Pain Assessment in Older Adults, copyright 2020, revealed in part, "Cognitive impairment [such as dementia] ... compromises older adults' ability to self-report pain. In patients with dementia ... other assessment approaches must be used to identify the presence of pain." "The ... process ... [is] as follows: ... look for an underlying cause of pain, such as surgery or a procedure [including the presence of signs of injury] ... observe for pain behaviors ... If any of these steps are positive, the nurse should assume that pain is present ..."



2. Review of Patient #1's Medical Record revealed:

a. On 6/25/20 at 11:57 AM, Physician's Assistant (PA-C) J documented they spoke with Physician K, who indicated they saw Patient #1 in their home and felt Patient #1 had a "significant cognitive decline over the past year."

b. The hospital staff admitted Patient #1 to the hospital's inpatient Geriatric Behavioral Health Psychiatric Unit on 6/25/20 at 2:23 PM. Psychiatrist I admitted Patient #1 to the hospital for weight loss, increased confusion, and the inability to care for themselves.

c. On 6/29/20 at 2:43 AM, RN B documented that Patient #1 got out of bed and walked into the hallway. A Patient Care Technician (PCT) asked Patient #1 if Patient #1 needed to use the bathroom, and Patient #1 indicated they needed to use the bathroom. The PCT went into Patient #1's bedroom to turn on the bathroom light and deactivate the bed alarm, which was alerting the hospital staff that Patient #1 had gotten out of bed without staff assistance. While the PCT went into Patient #1's room, RN B left Patient #1 alone (despite knowing Patient #1 was at risk for falling) and went to check on another patient. After RN B left Patient #1 alone, RN B and the PCT heard a crash and Patient #1 yell. Patient #1 had stumbled and fallen forward. RN B found Patient #1 laying on their left side, on the floor. Patient #1 indicated they had pain in their left leg after the fall and could not stand on their left leg. Patient #1 could not describe their pain, except "it hurts 'a little'" when Patient #1 was not moving. Patient #1 could not rate their pain, due to Patient #1's dementia. RN B assisted Patient #1 to a wheelchair to assist Patient #1 back to bed. RN B notified Psychiatrist N of Patient #1's fall.

d. On 6/29/20 at 2:15 AM, RN B documented they contacted Psychiatrist N regarding Patient #1's fall at 2:30 AM. Following Patient #1's fall, Patient #1 could not rate their pain in numbers on a 0-10 scale, but Patient #1 indicated they had throbbing pain in their left leg. RN B documented that Patient #1 had weakness in their left leg. RN B did not document any of the injuries Patient #1 suffered during the fall.

e. On 6/29/20 at 12:03 PM (approximately 9 hours after Patient #1 fell), RN E documented Patient #1 had generalized weakness during their assessment of Patient #1, but failed to document the injuries from Patient #1's fall. RN E failed to document if Patient #1 had an underlying cause of pain or if Patient #1 displayed non-verbal signs of pain.

f. On 6/29/20 at 4:31 PM (approximately 13 hours after Patient #1 fell), Psychiatrist I documented they examined Patient #1. Psychiatrist I noted Patient #1 fell during the night and noted that Patient #1 had provided conflicting information to the nursing staff about the presence of pain. Psychiatrist I's note indicated Patient #1's "Gait/station/muscle strength/tone:" was "without noted abnormalities. Lying down throughout [the exam]." Psychiatrist I did not document any information indicating they assessed Patient #1's left leg to determine if Patient #1 suffered any injuries from the fall, despite nursing staff reporting the fall. Psychiatrist I did not order an x-ray to determine if Patient #1 had broken their hip during the fall, despite documenting Patient #1 suffered from dementia (which could limit Patient #1 from comprehending the pain from the fall).

g. On 6/29/20 at 6:47 PM (approximately 14 hours after Patient #1 fell), RN F documented Patient #1 denied any pain and could walk as Patient #1 desired. RN F failed to document the injuries from Patient #1's fall. RN F failed to document if Patient #1 had an underlying cause of pain or if Patient #1 displayed non-verbal signs of pain.

h. On 6/30/20 at 5:37 AM (approximately 27 hours after Patient #1 fell), RN B documented that Patient #1 required assistance to transfer to a bedside commode. Patient #1 complained of pain while transferring, but did not complain of pain once staff assisted Patient #1 to bed (when broken bones move, they can cause pain and stop causing pain when the bones stop moving, such as laying in a bed).

i. On 6/30/20 at 9:01 AM (approximately 31 hours after Patient #1 fell), RN E documented Patient #1 could not rate their pain on a 0-10 scale. RN E noted Patient #1 could only indicate they had pain in their left leg.

j. On 6/30/20 at 10:30 AM (approximately 32 hours after Patient #1 fell), RN G documented Patient #1 rated the pain in their left hip at 8 out of 10, on a 0-10 scale, indicating severe pain. RN G noted Patient #1 did not consistently describe their pain at the same level, but noted Patient #1 could not walk due to the pain.

k. On 6/30/20 at 10:49 AM (approximately 33 hours after Patient #1 fell), RN G documented Patient #1 had "generalized weakness," but failed to document the injuries to Patient #1's left hip and leg from Patient #1's fall. RN G failed to document if Patient #1 had an underlying cause of pain or if Patient #1 displayed non-verbal signs of pain.

l. On 6/30/20 at 12:00 PM (approximately 35 hours after Patient #1 fell), RN E documented Patient #1 denied any pain. RN E failed to document if Patient #1 had an underlying cause of pain or if Patient #1 displayed non-verbal signs of pain.

m. On 6/30/20 at 1:12 PM (approximately 37 hours after Patient #1 fell), Psychiatrist I ordered the nursing staff to consult Resident Physician L regarding Patient #1's left hip pain.

n. On 6/30/20 at 4:15 PM (approximately 41 hours after Patient #1 fell), RN B documented Patient #1 denied any pain. RN B failed to document if Patient #1 had an underlying cause of pain or if Patient #1 displayed non-verbal signs of pain.

o. On 6/30/20 at 4:17 PM (approximately 41 hours after Patient #1 fell), RN H documented Patient #1 had "injury/trauma" to Patient #1's left hip. RN H failed to document if Patient #1 exhibited any non-verbal signs of pain.

p. On 6/30/20 at 4:25 PM (approximately 42 hours after Patient #1 fell), RN G documented that Patient #1 could not stand on their left hip, due to discomfort. Patient #1 would point to their left hip and indicate they had pain in their left hip, but could not rate their pain and would not always identify they experienced pain (common in patients with dementia). Patient #1 (who was normally able to walk) was in a wheelchair during the day, due to their inability to stand on their left leg.

q. On 6/30/20, RN H documented they assessed Patient #1 at 4:32 PM that day. RN H noted Patient #1 was confused, complained of left leg pain, and and could not move their left leg. Patient #1 had a bulge in their left hip, Patient #1's left leg was rotated counterclockwise, and Patient #1's left leg was shorter than Patient #1's right leg (all signs that Patient #1 broke their hip during the fall). Patient #1 rated their pain at 7/10 (severe pain), but would not consistently say they had pain (common in patients with dementia). Patient #1 underwent an x-ray of their left hip on 6/30/20 at 7:30 PM. When Patient #1 returned from the x-ray at 7:55 PM, the nursing staff kept Patient #1 on the transport cart, to minimize the pain for Patient #1 from transferring between beds. The nursing staff transferred Patient #1 from the inpatient behavioral health geriatric psychiatric unit to a regular medical/surgical room at 10:20 PM on 6/30/20.

r. On 6/30/20 at 4:52 PM (approximately 42 hours after Patient #1 fell), RN H documented Patient #1 rated the pain in their left hip at 8 out of 10, on a 0-10 scale, indicating severe pain. RN H documented Patient #1 could not walk due to the pain.

s. on 6/30/20 at 5:10 PM (approximately 42 hours after Patient #1 fell), Resident Physician L documented the nursing staff reported that Patient #1 fell early in the morning on 6/29/20 while attempting to walk in the hallway. Patient #1 could not walk after the fall, due to pain in their left hip. Patient #1 identified they had pain, but could not specifically describe their pain, due to their dementia. Resident Physician L's physical exam noted Patient #1's left leg was rotated counterclockwise and a bulge in Patient #1's left hip. Patient #1 had tenderness when Resident Physician L attempted to rotate Patient #1's left leg to the right or flex Patient #1's leg at the hip (all signs Patient #1 broke their hip during the fall). Resident Physician L ordered an x-ray of Patient #1's left leg.

t. On 6/30/20 at 5:55 PM (approximately 43 hours after Patient #1 fell), Resident Physician L ordered an x-ray of Patient #1's left hip.

u. On 6/30/20 at 8:01 PM (approximately 44 hours after Patient #1 fell), Radiologist M (a physician with specialized training in reading x-rays) reviewed the x-ray of Patient #1's left hip, and determined the bone in Patient #1's left femur broke into two pieces and separated a mild to moderate distance in Patient #1's leg.

v. On 6/30/20 at 9:01 PM (approximately 45 hours after Patient #1 fell), Resident Physician L documented they reviewed the results from Patient #1's left hip x-ray. The x-ray revealed that Patient #1 broke their left hip, and the femur (the large bone in the thigh) was mildly to moderately separated. Resident Physician L ordered the nursing staff to transfer Patient #1 to a regular medical/surgical room.

w. On 7/1/20 at 12:00 PM (approximately 57 hours after Patient #1 fell), Patient #1 underwent surgery to repair their broken hip.



3. During an interview on 07/09/20 at 8:00 AM, RN B revealed Patient #1 was able to get up on their own and walk without staff assistance, but after Patient #1 fell, Patient #1 required 1 to 2 staff members to assist Patient #1 to get up out of bed. Immediately following Patient #1's fall, RN B recalled Patient #1 was struggling to bear weight on left leg so staff got a wheelchair to help Patient #1 get back to bed. RN B notified Psychiatrist N of the fall but did not hear back from Psychiatrist N that night. RN B stated Patient #1 did not complain of pain when lying in bed, but Patient #1 did complain of pain when getting up out of bed. RN B took care of Patient #1 again on 06/30/20 (the next night after Patient #1 fell) and noted that there were no new orders to address Patient #1's pain or decline in independent activity. RN B noted that Patient #1 was not complaining of pain but Patient #1 continued to struggle to get up out of bed. Patient #1 required at least 1, sometimes 2 staff to assist when getting out of bed due to Patient #1's difficulty bearing weight on their left leg. RN B acknowledged that it would be normal to have pain with a broken hip, and noted that sometimes people with dementia have difficulty communicating their pain.


4. During an interview on 07/09/20 at 8:30 AM, RN E confirmed Patient #1 was up and walking without assistance before the fall, and after the fall Patient #1 just laid in bed. RN E revealed Patient #1 was kind of irritable and didn't want to get up out of bed on the morning after the fall. Patient #1 required two staff to assist from the bed to the wheelchair due to weakness when standing up. Patient #1 did not always communicate the presence of pain, and when Patient #1 complained of left leg pain Patient #1 was unable to articulate the level of pain (based on a 1-10 scale). RN did note that Patient #1's behavior was "kind of odd" and RN E conveyed this information to the physicians during their morning rounds, RN E did not receive any specific orders to address Patient #1's pain or decline in independent activity.

Based on document review and staff interviews, the acute care hospital administrative staff failed to ensure the behavioral health nursing staff developed, and kept current, an individualized plan of care to identify fall risks, and consistently implement appropriate interventions based on that risk, for 1 of 1 patients (Patient #1) who sustained a fall with injury while an inpatient on the geriatric behavioral health unit. Failure to develop and implement an individualized plan of care resulted in staff failing to identify appropriate interventions to keep patients safe from falls, which resulted in the staff failing to implement safety precautions to prevent Patient #1 from falling and breaking their hip, which required surgery to repair, potentially leading to an increased risk of death. The hospital staff identified an average daily census of 524 patients for the hospital, and an average daily census of 44 patients for the Behavioral Health unit.


Findings include:

1. Review of the policy "Fall Prevention Program", dated 10/2017, revealed in part, " ... The Fall Prevention Program includes: A patient risk assessment (Fall Risk & Injury from Fall Risk) done upon admission, Reassessments done at periodic intervals ... Implementation of patient specific interventions based on risk factors ... In areas serving adults the RN [Registered Nurse] will use the Hester-Davis screening tool and the ABCs of Harm [Age over 85, Bone disorders, Coagulation disorders (e.g., bleeding, use of blood thinners), Surgery... Any individual deemed at risk for fall or harm per above screening tools, will have fall/harm preventions implemented and individualized in the patient care plan in collaboration with the patient and family." The policy lacked any guidance to the nursing staff regarding interventions to implement to prevent patients from falling, except for the requirement to individualize the patient's care plan (a listing of the patient's nursing problems and nursing interventions the staff implemented to attempt to address the patient's nursing problems).

2. Review of "Prevention of Falls & Harm from Falls", last reviewed/revised 06/2020, revealed in part, " ... The patient will be assessed ... once every 12-hour shift ... all patients with either a high risk to fall or a high risk to be harmed from a fall will have individualized interventions integrated into their nursing care plan ... A score of 10 or below is low fall risk. A score of 11 or above is high fall risk." The policy lacked any guidance to the nursing staff regarding interventions to implement to prevent patients from falling, except for the requirement to individualize the patient's care plan.



3. Review of Patient #1's medical record revealed:

a. On 06/25/20 at 2:23 PM, Patient #1 was admitted to the Behavioral Health Geriatric Psychiatric unit. Patient #1 was admitted to the hospital for weight loss, increased confusion, and the inability to care for themselves at home due to their dementia.

b. On 06/25/20 at 7:00 PM, RN A documented Patient #1 had a Fall Risk Assessment Score of 14 (high fall risk). RN A documented they implemented Fall/Injury Risk interventions included placing Patient #1 close to the nurses' station, placing a yellow armband indicating Patient #1 was at high risk for falling on Patient #1, having Patient #1 wear yellow colored socks to indicate Patient #1 was at high risk of falling, signage indicating Patient #1 was at risk for falling, orthostatic precautions (precautions indicating Patient #1 was at risk for falling due to lightheadedness from standing up too quickly), video monitoring, and a floor mat in Patient #1's room. Despite RN A indicating they implemented numerous interventions to prevent Patient #1 from falling, RN A did not include fall risk as a patient problem in Patient #1's nursing care plan.

c. On 06/26/20 at 5:15 AM, RN B documented a Fall Risk Assessment Score of 14 (indicating Patient #1 was at high risk for falling). RN B documented that Patient #1 had been placed close to the nurses station and "precautions maintained".

d. On 06/26/20 at 8:20 AM, RN C documented a Fall Risk Assessment Score of 14 (the same Fall Risk Score as RN A documented on 6/26/20 at 7:00 PM). RN C documented they implemented fall prevention interventions for Patient #1 including placing Patient #1 close to the nurses' station, a yellow colored armband, yellow colored socks, and placing signage outside Patient #1's room.

e. On 06/26/20 at 9:19 AM, RN C did not include fall risk as a patient problem in Patient #1's care plan.

f. On 06/26/20 at 3:50 PM, LPN D documented a Fall Risk Assessment Score of 14 (the same Fall Risk Score as RN A documented on 6/26/20 at 7:00 PM). LPN D documented they implemented fall prevention interventions for Patient #1 including placing Patient #1 close to the nurses' station, a yellow colored armband, yellow colored socks, placing signage outside Patient #1's room, and utilizing video monitoring of Patient #1.

g. On 06/26/20 at 4:41 PM, LPN D did not include fall risk as a patient problem in Patient #1's care plan.

h. On 06/27/20 at 4:30 AM, RN B added Risk of Falls to Patient #1's care plan (approximately 36 hours after RN A first identified Patient #1 as a high risk for falling). RN B did not identify any interventions on Patient #1's care plan to prevent Patient #1 from falling.

i. On 06/27/20 at 4:31 AM, RN B documented a Fall Risk Assessment Score of 14 (the same Fall Risk Score as RN A documented on 6/26/20 at 7:00 PM). RN B documented the only fall preventions interventions they implemented for Patient #1 was placing Patient #1 in a room close to the nurses' station.

j. On 06/27/20 at 3:30 PM, LPN D documented a Fall Risk Assessment Score of 14 (the same Fall Risk Score as RN A documented on 6/26/20 at 7:00 PM). LPN D documented they implemented fall prevention interventions for Patient #1 that included a yellow armband, yellow colored socks, signage outside Patient #1's room that indicate Patient #1 was at risk for falling, using video monitoring, and placing a floor mat in Patient #1's room.

k. On 06/28/29 at 4:45 AM, RN B documented a Fall Risk Assessment Score of 14 (the same Fall Risk Score as RN A documented on 6/26/20 at 7:00 PM). RN B documented they only implemented fall prevention interventions for Patient #1 was using video monitoring.

l. On 06/28/20 at 4:43 PM, LPN D documented a Fall Risk Assessment Score of 14 (the same Fall Risk Score as RN A documented on 6/26/20 at 7:00 PM). LPN D documented they implemented fall prevention interventions for Patient #1 that included using video monitoring, a yellow armband, yellow colored socks, and signage outside Patient #1's room that indicated Patient #1 was at risk for falling.

m. On 06/29/20 at 2:15 AM, RN B documented a Fall Risk Assessment Score of 18 (a higher Fall Risk Score as RN A documented on 6/26/20 at 7:00 PM). RN B documented the only intervention they implemented for Patient #1 was using video monitoring.

n. On 06/29/20 at 2:55 AM, RN B documented Patient #1 got out of bed and walked without nursing staff assistance to the hallway. A Patient Care Technician (PCT) asked Patient #1 if Patient #1 needed to use the bathroom. The PCT left Patient #1 standing in the room, so the PCT could turn on the bathroom light and turn off the bed alarm (the nursing staff had not previously documented utilizing a bed alarm to notify staff if Patient #1 got out of the bed). RN B left Patient #1 standing alone, to assist another patient. RN B and the PCT heard a crash from Patient #1's room and Patient #1 yell. Patient #1 had stumbled and fell forwards. Patient #1 was laying their left side, on the floor. Patient #1 began complaining of pain in their left leg. Patient #1 could not stand on their left leg and "hurt all over." RN B assisted Patient #1 to bed, activated the bed alarm, and documented "fall protocol initiated." RN B notified Psychiatrist I about the fall, and Psychiatrist I indicated they would follow up in the morning. Patient #1's medical record lacked documentation of what fall prevention interventions RN B initiated following Patient #1's fall.

o. On 06/29/20 at 4:14 AM (1 hour after Patient #1 fell), RN B documented they reviewed Patient #1's care plan and documented Patient #1's goal of not falling was "not progressing." RN B did not document they implemented any additional interventions to prevent Patient #1 from falling again.

p. On 06/29/20 at 4:16 AM, RN B documented a Fall Risk Assessment Score of 18 (the same fall risk RN B documented prior to Patient #1's fall about 1 hour earlier). RN B documented the only intervention they implemented for Patient #1 was using video monitoring.

q. On 06/29/20 at 12:03 PM (approximately 9 hours after Patient #1 fell), RN E documented a Fall Risk Assessment Score of 20 (a higher score than Patient #1 had previously received). RN E documented they implemented fall prevention interventions for Patient #1 that included a yellow armband, yellow colored socks, signage outside Patient #1's room that indicated Patient #1 was at risk for falling, placing Patient #1 in a room close to the nurses' station (already implemented), a bed/chair alarm, orthostatic precautions, video monitoring, a floor mat in Patient #1's room, and for the staff to assist Patient #1 with walking.

r. On 6/29/20 at 4:31 PM (approximately 13.5 hours after Patient #1 fell), Psychiatrist I documented they examined Patient #1. Psychiatrist I noted Patient #1 fell during the night and provided conflicting information to the nursing staff if Patient #1 was experiencing pain.

s. On 06/29/20 at 6:42 PM (approximately 16 hours after Patient #1 fell), RN F documented a Fall Risk Assessment Score of 20. RN F documented they implemented fall prevention interventions for Patient #1 that included a yellow armband, yellow colored socks, and signage outside Patient #1's room that indicated Patient #1 was at risk for falling.

t. On 06/30/20 at 5:39 AM (approximately 27 hours after Patient #1 fell), RN B documented a Fall Risk Assessment Score of 20. RN B documented they implemented fall prevention interventions for Patient #1 that included a yellow armband, yellow colored socks, and signage outside Patient #1's room that indicated Patient #1 was at risk for falling.

u. On 06/30/20 at 10:49 AM (approximately 32 hours after Patient #1 fell), RN G documented a Fall Risk Assessment Score of 20. RN G documented they implemented fall prevention interventions for Patient #1 that included a yellow armband, yellow colored socks, and signage outside Patient #1's room that indicated Patient #1 was at risk for falling.

v. On 06/03/20 at 4:17 PM (approximately 37 hours after Patient #1 fell), RN H documented a Fall Risk Assessment of 22 (a higher score than previously documented for Patient #1). RN H documented they implemented fall prevention interventions for Patient #1 that included a yellow armband, yellow colored socks, video monitoring, and signage outside Patient #1's room that indicated Patient #1 was at risk for falling.

w. On 06/30/20 at 7:40 PM (approximately 41 hours after Patient #1 fell), a radiology report revealed Patient #1 had broken their left hip. The nursing staff transferred Patient #1 from the inpatient behavioral health unit to a general nursing floor, for treatment of Patient #1's broken hip.

x. On 7/1/20 at 12:00 PM (approximately 57 hours after Patient #1 fell), Patient #1 underwent surgery to repair their broken hip.



4. During an interview on 06/30/20 at 2:20 PM, during a tour of the behavioral health unit, the Behavioral Health Director explained that the Behavioral Health Geriatric Psychiatric unit had cameras in the patients' rooms. However, the nursing staff do not regularly or reliably monitor the cameras in the patients' rooms, and thus could not use the cameras as a fall prevention intervention to identify if a patient attempted to get out of bed without staff assistance and summon staff to the patient's room to assist the patient prior to the patient falling.


5. During an interview on 07/09/20 at 8:00 AM, RN B revealed that on the night Patient #1 fell, Patient #1 was able to get up on their own and walk without staff assistance, but after Patient #1 fell, Patient #1 required 1 to 2 staff members to assist Patient #1 out of bed. Following Patient #1's fall, RN B recalled adding a bedside commode and a bed alarm as fall prevention interventions for Patient #1 (RN B did not document implementing the bedside commode and RN B documented the bed alarm was activated prior to Patient #1 falling, as the bed alarm alerted the nursing staff Patient #1 had gotten out of bed without assistance).

The behavioral health nursing staff individualized each patient's fall prevention interventions based on the individual patient and the patient's individual fall risk. The staff perform routine rounds (every 15 minutes) and the patient rooms have cameras to allow the staff to monitor the patients. However, the staff get busy and do not specifically watch the cameras to ensure the patients are safe.

RN B believed the admitting nurse implemented fall preventions for patients upon admission to the behavioral health unit. However, the nursing staff are busy and in a hurry, so the nurses only document the fall interventions they observed in the patient's rooms, versus following standardized guidance for fall interventions based on the patient's fall risk score. Since the nurses are often busy, they do not look at the patient's care plan to determine what fall prevention interventions should be implemented for the patient.

RN B noted several occasions where RN B had difficulty determining which fall prevention interventions another nurse had implemented due to the other nurse charting they implemented different interventions than what RN B observed in the patient's room. However, since the nurses were too busy to take the time to determine which interventions should have been implemented, the nurses normally only charted the fall prevention interventions they observed in the patient's room and did not follow standardized guidance from a policy on which interventions to implement for patients with varying fall risks.


6. During an interview on 07/09/20 at 8:30 AM, RN E verified they took care of Patient #1 on the morning of 6/29/20, after Patient #1 fell. RN E could not recall what interventions the nursing staff implemented after Patient #1 fell, but guessed if the nursing staff had implemented any new interventions, the nursing staff would have documented the interventions in Patient #1's medical record (the medical record lacked evidence the nursing staff implemented any interventions the nursing staff had not previously implemented after Patient #1 fell).

RN E confirmed the nursing staff assessed the patients' fall risk every shift. If a patient scored "very high" on the fall risk assessment (a term not defined in the fall risk policy and thus, subject to a nurse's individual discretion), the nursing staff would closely monitor the patient and ensure the patient wore a yellow armband to indicate their fall risk status to other staff members. While the care plan may instruct nursing staff members to perform specific interventions to prevent a patient from falling, the nursing staff do not check the care plan to identify which fall prevention interventions they should utilize. Instead, the nursing staff rely on a verbal shift to shift report (subject to cascading miscommunications) to communicate a patient's fall risk and fall prevention interventions.

RN E could not identify a process for nurses to determine if they implemented appropriate fall prevention interventions based on a patient's fall risk score. Instead, RN E would observe the fall prevention interventions in the patient's room, assume those were appropriate, and document those as the fall prevention interventions they implemented. If RN E had a question about whether or not fall risk intervention was appropriate for a patient RN E would ask the supervisor, problem solve with other nurses, or would look at the fall risk assessment. RN E indicated if the patient's fall risk was "really high," a patient would probably need a bed alarm or floor mat.


7. During an interview on 07/20/20 2:00 PM, the Behavioral Health Education Specialist identified the nursing staff normally communicate information about patient needs, such as a patient's fall risk and interventions to prevent patients from falling, in the nurse to nurse verbal shift report (subject to cascading miscommunications). The Education Specialist was unable to identify a process and/or nursing practice to identify and document specific interventions to mitigate fall risk individualized for each patient.