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Based on observation, interview and record review the RN staff failed to adequately supervise and enforce the fall prevention policy for three of ten patients (ID #,4,5,6) in the senior care unit.

Findings included:

Record review of the facility policy "Fall Prevention", revised 12/2019
Patient to wear non-slip footwear whenever out of bed. Place a falls wristband on patient if indicated as assessed by the Morse Fall Prevention Algorithm.

Observation, of patient records, interview, and record review on 11/29/2022 at 1025 revealed patient (#4) had no history of falls, but had an unsteady gait, patient (ID#5,6) had a history of falls.

Observation of patient (ID#4, 5,6) wrist, revealed they had no yellow arm band on.
Interview with the nurse (ID#56) during observation, stated all the patients were a fall risk, and they were assessed by the Morse fall prevention algorithm upon admission. She (ID#56) verified that patient (ID#4,5,6) should have a yellow arm band on and fall prevention socks.

Observation of the senior care unit on the morning of 11/30/2022, revealed the staff placing yellow arm bands on all 19 patients in the unit.