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Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure the patient and or the patient's representative was given adequate information related to their health status for one (1) of ten (10) sampled patients (Patient #1). This failure to provide information violated the patient's right to request or refuse treatment when Patient #1 sustained a fall and the family was not notified.

The findings include:

Review of the facility policy titled "Disclosure of Unanticipated Outcomes", revealed it was received via FAX by the State Agency on 05/17/13, after the exit date of 05/16/13. Continued review of the policy revealed the following: "disclosure of unanticipated outcomes of care should be made to the patient, and when appropriate, the patient's family....., [and] disclosure should occur as soon as practical after the event has occurred or been identified".

Review of the State Agency Complaint Intake Form revealed Patient #1 had a fall at the facility. Continued review revealed the family was never notified of the fall. Further review revealed the family learned the patient had fallen from the receiving facility after the patient was transferred for long-term care.

Review of the clinical record revealed Patient #1 was admitted by the facility on 04/19/13 with diagnoses which included Congestive Heart Failure, Pulmonary Hypertension, Urinary Tract Infection, E. coli Bacteremia, Multiple Myeloma, and Generalized Weakness and Debility.

Review of the Patient Care Flowsheet dated 04/25/13, revealed Patient #1 sustained a fall in the bathroom at 1:30 AM. Continued review revealed no indication the family was notified of the incident.

Interview with the Unit Manager, on 05/14/13 at 1:57 PM, revealed she was a member of the Falls Committee. She stated falls were considered "top priority". She further stated the family should be notified every time there was a fall.

Interview with the Clinical Nurse Specialist (CNS), on 05/16/13 at 3:05 PM, revealed she was the leader of the Falls Committee. She stated her responsibilities included reviewing fall incidents to determine a root cause analysis and tracking data related to falls. Review of the Incident Report with the CNS revealed it was completed by the nurse caring for Patient #1 at the time of the fall. Continued review revealed the nurse documented "not applicable" in the section for family notification.

Interview with Registered Nurse (RN) #2, on 05/16/13 at 4:25 PM, revealed he did not recall the incident of Patient #1 falling on 04/25/13. He stated he did not know the facility policy related to notification of family after a fall. He further stated he felt it was a matter of nursing judgment.

Based on interview and record review, and review of facility policy, it was determined the facility failed to ensure an ongoing evaluation of the patient's care needs, including the patient's response to interventions, for one (1) of ten (10) sampled patients. Patient #1 was treated for pain on multiple occasions. Documentation related to the patient's pain management did not include the location or character of the patient's pain.

The findings include:

Review of the policy titled "Pain Management Protocol", issued 07/2001 and most recently revised 02/2011, revealed the following: a pain assessment was to be completed on admission and at least every four (4) hours thereafter; pain assessments were to include (but not be limited to) the location and character of the pain; the cause of the patient's pain was to be determined whenever possible; and all pain assessment findings were to be documented on the Patient Care Flowsheet.

Review of the clinical record revealed the facility admitted Patient #1, on 04/19/13, with diagnoses which included Congestive Heart Failure, Pulmonary Hypertension, Urinary Tract Infection, E. coli Bacteremia, Multiple Myeloma, and Generalized Weakness and Debility.

Review of the Patient Care Flowsheet dated 04/25/13, revealed Patient #1 sustained a fall in the bathroom at 1:30 AM. Continued review revealed the patient was assessed for pain seven (7) times between 6:00 AM and midnight on 04/25/13, every four (4) hours as required. On each assessment, the patient rated the pain at a level of ten (10) on a scale of one (1) to ten (10), with ten (10) being the most severe. Further review revealed Patient #1 was treated for pain on each occasion with oral or intravenous pain medication. On only one (1) occasion, the nurse documented the patient complained of "generalized pain". However, there was no other documented evidence of the location or character of the patient's pain, nor was there consistent documentation of the patient's response to the pain interventions. In addition, there was no documented evidence of attempts to determine a cause of the pain, including whether or not the pain could have been a result of the patient's fall.

Interview with the Unit Manager, on 05/16/13 at 2:30 PM, revealed the location of the patient's pain and the response to interventions should be documented on each pain assessment.

Interview with the Director of Nursing (DON), on 05/16/13 at 2:35 PM, revealed the nurse should include the location and character of pain on each assessment.

Interview with Registered Nurse #1, on 05/16/13 at 2:50 PM, revealed the pain assessment should included the location of the patient's pain.

Interview with the Clinical Nurse Specialist, on 05/16/13 at 3:05 PM, revealed the documented pain assessments for Patient #1 were incomplete because they did not include the location of the patient's pain, a cause of the pain, or the patient's response after medications were administered.