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Based on interview and record review, the facility failed to ensure 1 of 10 patient's right (Patient #1) to care in a safe setting, as evidenced by the failure of staff to turn on Patient #1's bed alarm.

Findings included:

TX00298057

Record review on 10/11/18 of Patient #1's clinical records revealed patient was a 75-year-old female with history of stroke with resultant left sided weakness. She was admitted to facility for rehabilitation and strengthening of musculature on 9/8/18 and discharged on 10/4/18. On 10/2/18, Patient #1 had fallen from her bed at an unknown time during the evening and sustained a bruise above the left eye. Patient was transferred to local emergency room, treated and released. Patient was discharged back to facility and instructed to follow-up with a neurologist and her primary care doctor after discharge from facility.

Further record review revealed a nursing progress note from Staff #51 dated 10/2/18 at 2:50 am, stated that CNA (Certified Nurse Assistant) Staff #52 found Patient #1 on floor in her room. It was determined the patient fell out of bed but it was unknown how long patient had been on the floor after falling.

In an interview on 10/11/18 at 11:15, Staff #54 stated that the investigation revealed that the patient's bed alarm was not turned on. Staff #54 stated the bed alarm should have been on due to the high fall risk, and it was the responsibility of the nurse to ensure this was done. Further interview revealed that the nurse responsible, Staff #51, falsified records and was subsequently terminated and reported to the nursing board. The facility had not instituted a fail-safe measure to ensure the prevention of a similar occurrence.

Record review on 10/11/18 of facility policy titled "Fall Prevention And Risk Assessment" dated 8/2/16, states for Extreme fall risks; "Bed alarm set on sensitivity level 1 unless otherwise ordered".