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Based on interview, record review and policy/procedure review the facility failed to ensure that 1( patient # 1) of 10 patients reviewed received care in a safe setting.

Findings:

During an interview on 05/05/16 at 2:48 PM, for patient#1 with the Director of Nursing (DON) stated that the Certified Nursing Assistant (CNA) was working as a Therapeutic Attendant (TA)/sitter, and was assigned to patient #. The CNA/TA turned off the patients bed alarm and was not reactivated prior to the CNA/TA/sitter leaving the patients room. The bed alarm did not sound at the time the patient fell.The DON stated the bed alarm is not to be turned off on patients needing the bed alarm. The TA that was assigned to patient #1 was standing in the patients door way, speaking with the RN charge nurse, when the patient fell. Neither the TA or the RN had eyes on the patient when the patient fell because the patients privacy curtain was closed. If the patients care plan states that patient needs constant bed/chair alarm must be on at all times. If the care plan indicates that a patient is to have a TA/Sitter 1:1 then the TA/Sitter is to with the patient 1:1.

During an interview on 05/05/16 at 3:23 PM with Staff (I) RN assigned to the patient on the night of patient # 1 falling stated, when she arrived on shift the patients bed alarm was not activated. She reactivated the alarm at the beginning of the shift and was unaware the alarm had been turned off again. The nurse did not hear the bed alarm sound before, during or after the patient fell. This RN questioned the TA immediately after the patient fell about the alarm not sounding. The TA admitted to the RN that she turned off the patients bed alarm before leaving the patients room. The assigned RN was seated across from the patients room when she heard a loud noise from the patients room.The TA that was assigned to the patient was standing in the hallway outside the pateints room when the patient fell.

During an interview on 05/05/16 at 4:04 PM, Staff E stated she was assigned to provide care for patient #1 on the night of his fall. The TA left the patients room leaving the patient alone. The TA was standing in the hallway without being able to see the patient because of the patients privacy curtain being closed when the patient fell. The TA admitted she turned Patient #1 bed alarm off before she left the patients room. The TA did not hear the patients bed alarm sound before, during or after he fell.
A review of the facility's policy/ procedure titled " Therapeutic Attendent" shows that a Therapeutic Attendant maybe utilized for cognitively and/or emotionally impaired patient, on the advice of the nursing staff and/or interdisciplinary team who, after assessment shows that patient is unsafe.The purpose of the TA is to provide a safe environment for the cognitively and/or emotionally impaired patient who exhibits maladaptive, inappropriate, or safety threatening behaviors that can affect the course of recovery, rehabilitation and discharge planning while ensuring patient's safety, dignity and well being.
A review of the facility's policy/procedure titled " Bed Alarm" shows that all staff will assure that bed alarms are set when rounding on the patient and each time the patient placed back in bed. The purpose of the alarm is to provide the nursing and other staff with an immediate auditory alarm that indicates the patient is attempting to get up.

Based on interview, medical record review, and policy/procedure the facility failed to ensure that the patient was adequately supervised and that nursing care was adequately provided for 1 (Patient # 1) of 10 Sampled Patients.Findings Include:Patient #1 medical record showed he was admitted to the facility on 09/26/2015 after he fell off a roof for rehabilitation services. A review of the medical record showed that the patient was to have a sitter( Therapeutic Assistant) and a bed/ chair alarm.
Review of the fall log shows that the patient was left alone by his assigned Therapeutic Assistant (TA). The patient fell to the floor in the absence of the TA and sustained a new head injury. The patients bed alarm was not activated at that time that the patient fell. The bed alarm did not alarm before during or after the patients fall.
During an interview on 05/05/16 at 2:48 PM, Director of Nursing (DON) stated that the assignment for patient # 1 was to be redone. The Charge Nurse assigned patient #1 a TA that had 2 patients the night patient # 1 fell. There was some miscommunication between the staff and the TA and the TA continued to provide care to 2 patients.
During an interview on 05/05/16 at 3:23 PM, Staff I assigned to the patient#1 on the night of his fall she stated, when she arrived on shift the patients bed alarm was not activated. The RN reactivated the alarm at the beginning of the shift and was not aware the alarm had been turned off again. The nurse did not hear the bed alarm sound before, during or after the patient fell. The RN questioned the TA about the alarm not sounding the TA admitted to the RN that she turned off the patients bed alarm before leaving the patients room.The TA that was assigned to the patient was standing in the hallway outside the patients room when the patient fell. Staff (I) further stated the RN charge nurse at the beginning of the shift assigned the TA to provide care for 2 patients on the assignment sheet.The RN was not made aware by the Charge Nurse or any other statt that the TA'S assignement had been changed.
During an interview on 05/05/16 at 4:04 PM, Staff E stated was assigned to provide care for patient #1 on the night of his fall. The TA left the patients room leaving the patient alone. The TA was standing in the hallway speaking to the RN charge nurse with the patients privacy curtain closed when the patient fell. The TA did not have visual observation of the patient. The TA confirmed she turned Patient #1 bed alarm off before she left the patients room. The TA did not hear the patients bed alarm sound before, during or after he fell. The TA stated she arrived at the facility the assignement sheet showed that she was assigned to 2 patients. The TA was not made aware by the Charge Nurse that the assignement had been changed.
A review of the facility's policy/ procedure titled " Therapeutic Attendent" shows that a Therapeutic Attendant maybe utilized for cognitively and/or emotionally impaired patient, on the advice of the nursing staff and/or interdisciplinary team who, after assessment shows that patient is unsafe.The purpose of the TA is to provide a safe environment for the cognitively and/or emotionally impaired patient who exhibits maladaptive, inappropriate, or safety threatening behaviors that can affect the course of recovery, rehabilitation and discharge planning while ensuring patient's safety, dignity and well being.
A review of the facility's policy/procedure titled " Bed Alarm" shows that all staff will assure that bed alarms are set when rounding on the patient and each time the patient placed back in bed. The purpose of the alarm is to provide the nursing and other staff with an immediate auditory alarm that indicates the patient is attempting to get up.

Based on interviews, medical record and policy/procedure review, the facility failed to ensure that the patient's nursing care plan was adequately followed for supervision for 1 ( Patient # 1) of 10 patients reviewed. Findings:Patient #1 medical record showed he was admitted to the facility on 09/26/15 after he fell off a roof. A review of the care plan dated 10/03/15 shows that three rails on the bed, both a bed/chair alarm are to be on at all times. To have one TA (Therapeutic Assitant) with patient # 1. further intervention s include rounding ( Checking patient) as per policy and to respond to all alarms/call bells promptly.
During an interview on 05/05/16 at 2:50 PM, the DON( Director of Nursing) stated the physician does not order 1:1 observation for patients, this is a nursing intervention. The care plan is a standard care plan and cannot be changed.
During an interview on 05/05/16 at 3:23 PM, Staff I, assigned to the patient on the night of his fall stated when she arrived on shift the patients bed alarm was not activated. She reactivated the alarm at the beginning of the shift and was unaware the alarm had been turned off again. The nurse did not hear the bed alarm sound before, during or after the patient fell. The RN questioned the TA about the alarm not sounding the TA admitted to the RN that she turned off the patients bed alarm before leaving the patients room. The TA that was assigned to the patient was standing in the hallway outside the pateints room when the patient fell. During an interview on 05/05/16 at 4:04 PM, Staff E stated she was assigned to provide care for patient #1 on the night of his fall. The TA left the patients room, leaving the patient alone. The TA was standing in the hallway without being able to see the patient because of the patients privacy curtain being closed when the patient fell. The TA admitted she turned Patient #1 bed alarm off before she left the patients room. The TA did not hear the patients bed alarm sound before, during or after he fell.
A review of the facility's policy/ procedure titled " Therapeutic Attendent" shows that a Therapeutic Attendant maybe utilized for cognitively and/or emotionally impaired patient, on the advice of the nursing staff and/or interdisciplinary team who, after assessment shows that patient is unsafe.The purpose of the TA is to provide a safe environment for the cognitively and/or emotionally impaired patient who exhibits maladaptive, inappropriate, or safety threatening behaviors that can affect the course of recovery, rehabilitation and discharge planning while ensuring patient's safety, dignity and well being.
A review of the facility's policy/procedure titled " Bed Alarm" shows that all staff will assure that bed alarms are set when rounding on the patient and each time the patient placed back in bed. The purpose of the alarm is to provide the nursing and other staff with an immediate auditory alarm that indicates the patient is attempting to get up.