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Based on document review and interview, it was determined that the hospital failed to protect and promote the rights for each patient. The hospital failed to ensure the implementation of facility policy regarding general safety and fall prevention (Refer to A 0395). The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the nursing services be supervised by a registered nurse.

Based on document review and interview, the registered nurse failed to ensure the implementation of facility policy regarding general safety and fall prevention for 4 of 10 patient records reviewed (Patients #3, #6, #7, and #10).

Findings:
1. Review of the policy "General Safety and Fall Prevention", policy number 600-1023, last revised on 2/21/14, indicated:
a. Page two reads "1. Each patient will be assessed by the registered nurse on admission to determine if the patient is at risk for fall. 2. The nurse is to reassess each patient's fall risk at least every 12 hours or as a change occurs...3. Appropriate measures will be instituted, based on patient need, as outlined in this procedure...".
b. Page two reads that moderate risk for falls = 25 to 44, and a high risk for falls is "45 and higher".
c. Page 3 reads: "1. Each patient is assessed on admission to the nursing unit for risk for fall by a RN (registered nurse) utilizing the Morse Fall Risk Assessment...".
d. Page 6 reads: "7. Additional fall prevention strategies to implement if the patient is determined to be at high risk for falling are, but are not limited to the following:...B. Identify patient by applying yellow wristband & yellow gown...c. Place a falling star outside of patient's room. d. Utilize bed alarm...".

2. Review of patient medical records indicated:
a. Pt. #3 had safety precautions noted on 3/14/15 while in the ED (emergency department). Per the medical record, the call system was in place, side rails were up x 2, and the bed position was low. No Morse fall risk score was performed for this patient prior to going to Ultrasound at 8:00 PM. When the patient went to Ultrasound, they stated they had fallen in the bathroom when changing clothes. The patient returned from Ultrasound at 9:30 PM with a hematoma over the right eye and an ice pack applied. The Morse score at that time was 60 (high risk = >44). There was no documentation that a yellow bracelet, to indicate the patient was a high risk for falling, or that a yellow gown was placed, prior to the patient's discharge from ED to home at 10:50 PM.
b. Pt. #6 presented to the ED on 6/9/15 at 7:34 AM. Discharge was at 11:12 AM to home in stable condition with a discharge diagnosis of leg pain, hip contusion. There was no Morse fall risk assessment completed on this patient.
c. Pt. #7, a 31 year old (pt. #6) who had been seen in the ED earlier on 6/9/15, later presented to the ED at 5:53 PM with "syncopal episodes". At 6:00 PM the Morse fall risk assessment indicated the patient scored at 20 (low risk). The patient fell at 9:00 PM and had no further Morse scoring done prior to admission to ICU (intensive care unit) at 12:40 AM on 6/10/15. The Morse score at 1:30 AM in ICU was 95, with no yellow wrist band or yellow gown noted as being provided.
d. Pt. #10 was an 80 year old admitted to the ED on 5/15/15. There was no Morse fall risk scoring done while the patient was in the ED from 11:52 PM on 5/15/15 to admission at 5:30 AM on 5/16/15. The first Morse score was noted as done at 7:15 PM on 5/16/15, not at the time of admission to the unit, as per facility policy. (Score was 20--low risk with patient on the ventilator.)

3. At 3:00 PM on 6/29/15, interview with ED RN #54 indicated:
a. The medical records, as listed in 2. above, were lacking documentation of having a Morse fall risk score performed and/or documentation of implementing high risk interventions for those who scored >44.
b. It was unknown if the EMR (electronic medical record) had a section for documenting the higher risk implementations, such as bed alarms, yellow wrist bands, yellow gowns, and falling stars.

4. At 4:40 PM on 6/29/15, interview with ED RN #55 indicated a "secondary screen" is available for nursing staff to document the high risk for fall interventions, as required per facility policy.