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Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure a patient's bed alarm was reactivated after providing patient care. This failure resulted in an Immediate Jeopardy, posing a serious risk of harm to the patients.
A discussion took place with the survey team and the facility's administrative staff (EMP1) regarding the survey team's concerns related to Nursing Services on December 16, 2024, at 11:36 AM.
On December 17, 2024, the survey team reviewed facility documents, education logs, audit logs, and interviewed staff to determine compliance for the removal of the Immediate Jeopardy.
The survey team verified these immediate interventions were implemented and confirmed the facility's Immediate Jeopardy was removed.
Cross reference:
482.23(b)(6)

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to maintain a safe environment for patients by failing to follow facility policy for implementing fall interventions for patients identified as a high-risk for falls.



Findings include:

Review on December 16, 2024, of facility policy "Fall Risk Reduction Interventions (Attachment B)," reviewed March 2024, revealed, "... Patients with High Risk Score (e.g. Morse = 45 and above and/or patients scoring 15 points under Mental Status; Predictive Model = 60-100) ... Use fall management equipment, e.g. audible bed/chair alarms ..."


Review on December 16, 2024, of MR1 nursing documentation revealed fall risk assessments were completed daily from November 29, 2024 - December 7, 2024. The patient's fall risk scores ranged between 94.07 and 96.78 placing the patient at a high risk for falling. Further review of MR1 revealed bed and chair alarms were included in the patients's safety interventions.

Review on December 16, 2024, of MR1 physician documentation "Progress Note" dated December 7, 2024, revealed "... Subjective & A/P (assessment and plan): Early morning patient had an episode of unwitnessed fall and being found near the door. With [patient's] head towards the wall. RRT (rapid response team) was called ... Patient underwent a CT of the head which was noted to have bilateral 4 mm subdural hemorrhages ..."


Interview on December 16, 2024, at approximately 9:40 AM confirmed staff members were providing care for the patient and deactivated the bed alarm. Further interview confirmed after the care was provided staff exited the room and did not reactivate the bed alarm.

cross reference:
482.23 Nursing Services