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Based on document review and interview, nursing staff failed to ensure all high fall precautions were in place at all times and failed to document fall precautions accurately for 1 of 10 patient Medical Records reviewed (P1) .

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview, nursing staff failed to ensure all high fall precautions were in place at all times and failed to document fall precautions accurately for 1 of 10 patient Medical Records reviewed (P1) .

Findings Include:

1. The policy titled "Risk for Fall and/or Entrapment Guidelines", last revised: 05/2025, PolicyStat ID: 17699367 indicated the under I. policy: Indication of Risk guidelines are provided to identify patients at risk for falling and/or entrapment and to implement strategies for fall and/or entrapment prevention. All patients need to be assessed using the Morse Fall Risk Scale at the time of admission, daily and when patients condition changes. III. Procedure: Once the patient is identified as being medium or high risk for fall per Morse Fall Risk Scale, additional interventions specific to the needs of the patient can be initiated to improve patient safety. These may include but not limited to if possible place patient close to nurses station, check patient every 1-2 hours and assess for reorienting patient, toileting needs . food/fluid needs, check tubing, close curtain at night, implement bed/chair alarm, implement bed/chair alarm for patients with medium or high fall risk.

2. Review of P1's medical record (MR) indicated the following:
a. Morse fall risk assessment on 04/29/2025 at 2300 hours indicated a total score of 80 points (High fall is 45 points or above).
b. Fall risk interventions dated 05/05/2025 at 1900 in place pre fall for P1 included, nonskid footwear, bedside commode in place, require moderate assist when out of bed, 2 side rails up on bed, bed alarm on, bed wheels locked, and room door open.
c. Review of Nurse progress note dated 05/05/2025 at 1935 hours N2 (Registered Nurse) indicated that P1 was found on the floor. Post fall wound documentation dated 05/05/2025 at 1935 hours indicated P1 had a laceration above the left eyebrow.
d. Review of the computed tomography (CT) of the head without intravenous therapy (IV) dated 05/05/2025 at 2027 hours indicated a large left frontal and forehead soft tissue hematoma, moderate chronic small vessel ischemic disease evidenced by periventricular white matter hypodensities. and mild diffuse volume loss with associated ventricular and sulcal prominence.

3. Review of Post Fall Huddle Review Form dated 05/05/2025 at 1935 hours indicated that P1 had a fall with a head laceration to the left forehead. Huddle report indicated the fall was preventable due to F1 failed to put the bed alarm on while he/she was in bed.

4. In interview on 07/07/2025 at approximately 1530 hours with staff member A3 (Director of Acute Care) indicated that P1 did not have his/her bed alarm on at the time of P1 fall and that MR indicated at 1900 hours F1 staff had documented bed alarm on.