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Based on medical record review, observations, staff interview, and policy review, the facility failed to place Fall Risk indicators on the door in accordance with it's policy for four (Patient #1, #5, #9 and #10) of seven rooms observed for patients with high risk for falls. The facility had 73 patients with high risk for falls at the time of the survey.

Findings include:

1. Review of the facility policy titled "Fall Prevention Policy," effective 09/21/20, revealed the Fall Prevention Program identifies patient/resident safety precautions, documentation requirements, and additional measures to protect patients/residents from injuries related to falls. The goal of this program is to readily identify those patients/residents who are at the greatest risk for falling, implement a plan of care to promote their safety, document the assessments and safety measures instituted, alert other care team providers to their patient's/resident's potential for falling, and provide guidelines for management of a patient/resident in the event of a fall. Interventions for patients with High Fall Risk include a Fall Risk indicator on the door.

2. Review of the medical record revealed Patient #1 admitted on 06/05/21. The physical therapy care plan indicated the patient was being seen for safety education with an intervention of a bed alarm in place. Patient #1's Morse Fall Risk Score was listed as 65 = High Risk identified as 45 or greater. Patient #1's room was observed on 06/07/21 at 11:48 AM without a Fall Risk indicator on the door.

The findings were shared with Staff A at the time of the observation and confirmed.

3. Review of the medical record revealed Patient #9 admitted on 05/12/21. Patient #9's Morse Fall Risk Score was listed as 45 = High Risk. The plan of care identified Patient #9 to be at risk for falls. Patient #9's room was observed on 06/07/21 at 11:50 AM without a Fall Risk indicator on the door.

The findings were shared with Staff A at the time of the observation and confirmed.

4. Review of the medical record revealed Patient #5 admitted on 06/02/21. The physical therapy care plan indicated the patient was being seen for safety education with an intervention of a bed alarm in place. Patient #5's Morse Fall Risk Score was listed as 60 = High Risk. Patient #5's room was observed on 06/07/21 at 11:50 AM without a Fall Risk indicator on the door.

The findings were shared with Staff A at the time of the observation and confirmed.

5. Review of the medical record revealed Patient #10 admitted on 05/31/21. The physical therapy care plan indicated the patient was being seen for safety education and training. Patient #10's Morse Fall Risk Score was listed as 85 = High Risk. Patient #10's room was observed on 06/07/21 at 11:51 AM without a Fall Risk indicator on the door.

The findings were shared with Staff A at the time of the observation and confirmed.

This is an incidental citation identified during the investigation into Substantial Allegation OH00122151.