The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure fall prevention interventions were implemented for one of two medical records reviewed (MR1).

Findings include:

Review on January 31, 2019, of the facility form "Notice Of Patient Rights and Responsibilities," dated September 2018, revealed " You have the right to : ...An environment that is safe..."

Review on January 31, 2019, of the facility's, "Fall Prevention Policy," revised January 15, 2018, revealed "I. Purpose and Scope: Creating a safe environment for patients by reducing falls and eliminating serious injuries from falls. The scope of this policy will include: 1. Definition of a fall 2. Assessing fall risk and applying evidence-based interventions. 3. Identify and effectively communicate patients that ate 'At Risk' to fall. 4. Reduce patient falls and eliminate falls resulting in serious injury. 5. Address repeat falls with a post-fall assessment and change in interventions. 6. Educate staff related to fall prevention and interventions that eliminate serious injuries from falls. 7. Educate patient, family and others on the fall prevention program. II. Policy: This Fall Prevention policy applies to all inpatient care settings and populations. III. Responsibilities: ...C. RN/Licensed staff (within scope of practice to perform a fall evaluation): a)To complete the fall-risk evaluation with the initial assessment. b)Notifying the charge nurse of new patients assessed as "High Risk" for falls. c)Following and implementing the fall interventions for 'At Risk' patients at time of admission d)During bedside shift report-verifies that all patients have the preventative/protective fall interventions in place. D. Staff Nurses (including RN, LPNs, Patient Care Technicians, CNAs and Contract Nursing Staff): a)Implementation and compliance with fall prevention and interventions that eliminate serious injuries from falls. b)Complete fall-risk (re)assessments when: Patient transfers from one unit to another With every shift assessment ...c)Ensuring interventions for patients 'At Risk' to fall are implemented, documented, and communicated during bedside shift report and during unit safety huddles. ...E. It is the responsibility of all employees to observe, monitor and intervene when necessary with patients identified 'At Risk' for falls to prevent a fall and eliminate serious injuries from falls. VI. Interventions to Prevent Falls and Serious Injuries from Falls: Based on the assessed Fall Risk Category; the following Interdisciplinary Interventions will be implemented and documented: ...High Risk to Fall: (Final risk score: > using [name of fall scoring tool] ...Apply High Risk to Fall yellow armband. Apply High Risk to Fall falling man magnet on door rim. Place High Risk to Fall identification on the white board for visual alerts. Bed alarms to alert staff when patient is attempting to get up and activate the use of chair alarms when patient is sitting up. Bedside floor mats for patients at risk of injury from a fall ... "

Review on January 31, 2019, of MR1 revealed the patient was admitted on [DATE], with a diagnosis of bilateral pulmonary embolisms.

Nursing documentation dated January 11, 2019, at 08:00 revealed MR1's fall score was 60. Further documentation revealed the bed was in low position, wheels locked, side rails up x 2, bed/stretcher in low position/brakes locked, call light in reach, instruction to call for assistance, remove unnecessary furniture from patient's room, orientation to room, apply fall risk armband, instruct patient/caregiver/family to ask for assistance, ensure bed is in lowest position when care is completed, reinforce teaching with patient and family as needed, siderails up at all times, night light as appropriate, elimination needs assessed and attended to. Continued documentation on January 11, 2019, at 10:55 revealed patient found to be on floor beside bed, leaning on elbow. Patient was awake and responsive. No documentation the bed alarm was in place was noted. No documentation the fall mats were in place was noted.

Review on January 31, 2019, of the facility provided "Post Fall Huddle Form" completed on January 11, 2019, revealed the bed alarm was not on at the time of the fall.

Interview on January 31, 2019, with EMP2 confirmed the bed alarm was not on at the time of the fall and the floor mats were not in place.