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Based on medical record review, policy review and staff interview it was determined the registered nursed failed to assess, intervene and evaluate care related to fall precautions for one (#2) of ten records reviewed.

Findings include:

Patient #2's initial nursing assessment dated 8/15/15 identified a hearing deficit, use of cane and walker for ambulation and needing assistance with Activities of Daily Living (ADLs). A fall risk assessment was performed. The patient was identified as moderate/high risk for falls with interventions for the bed in low position, call device within reach, intentional rounds, assistance with toileting, bed exit alarm and fall risk band. The care plan for falls was initiated.

On 8/16/15 at 2:00 p.m. the patient care technician (PCT) noted on rounds that safety precautions were in place, bed alert on, call device within reach, non-slip footwear, patient ID band and the wheels locked. On 8/16/15 at 6:05 p.m. the nurse documented at 5:45 p.m. the patient fell in the room. Documentation revealed Nurse Leader Rounding/Patient rounds was performed at 4:19 p.m. that included safety rounds. The patient was noted to be hard of hearing and confused.

Interview with the Nurse Manager on 9/30/15 at approximately 11:45 a.m. confirmed the findings. Additionally, the Nurse Manager stated staff reported the bed alarm did not sound to alert staff the patient was out of bed. It was found the bed plug was not secured. The maintenance staff secured the plug and tested the bed showing the bed alarm was working when secured.

The review of the facility's policy "Documentation: Nursing" Policy # NCL0008, Last review 8/2014 noted on page 2 of 2 that two hour nursing interventions to be documented electronically whenever the following interventions are completed: a. Patient rounds b. toileting, while awake if applicable and d. turn and reposition.