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Based on a review of facility policy, other facility documents and medical records (MR), observation and staff interview, it was determined that the facility failed to ensure patients received care in a safe environment by failing to follow adopted policies related to fall precautions for eight of 15 medical records ( MR2, MR3, MR6, MR8, MR9, MR10, MR11 and MR14).

Findings include:

Review of facility document "HealthSouth Patient Rights and Responsibilities - Inpatient" reviewed 2010 revealed "The patient has the right to: ...Expect personnel who care for the patient to be friendly, considerate, respectful and qualified through education and experience, as well as perform their responsibilities with the highest quality of service. ...Receive care in a safe setting."

Review of "The Hospital & Healthsystem Association of Pennsylvania Patient Rights & Responsibilities" adopted by the facility and revised 2011 revealed "...Your rights...Care Delivery You have the right to: ...Receive kind, respectful, safe, quality care delivered by skilled staff."

Review of facility policy "Assessment of Patient Needs/Identification of Patient Care Needs" revised/reviewed July 2010 revealed "Purpose: A. To provide optimal nursing care in accordance with individualized patient needs. ...Policy: The HealthSouth Rehabilitation Hospital of Sewickley Professional Nurse uses the nursing process to plan nursing care based on a documented assessment of individualized patient care needs. These needs are reassessed and evaluated beginning with admission throughout the inpatient stay and including discharge. ...C. ...4. The patient's medical record includes documentation of the following: ...b. identification of patient care needs c. nursing interventions and teaching to meet identified patient and significant other needs."

Review of facility policy "Low Bed Guidelines" revised/reviewed July 2009 revealed "...Guidelines: 1. The low bed is a restraint alternative. 2. If a patient's fall risk assessment is 45, unless contraindicated, the patient is recommended to be placed in a low bed with a bed alarm, and a wheelchair alarm should also be placed on the wheelchair."

Review of facility policy "Interdisciplinary Plan of Care - Inpatient" reviewed/revised October 2010 revealed "...Policy: It is the policy of HealthSouth Rehabilitation Hospital that each patient admitted will have an IPOC [Interdisciplinary Plan of Care] developed, which will be based on his/her assessed individual needs, family caregiver needs, physical, cognitive and functional impairments, and co-morbid conditions. Procedure: ...5. Each body system or functional area will have identified problems documented, followed by specific interventions identified to meet the needs of the patient. ...18. Updates to the IPOC are documented in the plan. Any new problems identified are checked any new interventions are dated and initialed. Any discontinued interventions are dated and initialed."

1. Review of MR2 on July 8, 2011, at approximately 10:30 AM revealed a Morse Fall risk Assessment of 85, dated June 8, 2011. The fall risk revealed, " > 45 Fall Risk Assessment then place patient in Low bed with bed alarm and use of wheelchair alarm."

Review of facility documents revealed that MR2 was found on the floor on June 12, 2011, at 2:00 AM and had "slid" out of of the wheelchair on June 14, 2011, at 1:45 PM.

Review of the Interdisciplinary Daily Documentation (IDD) dated June 14, 2011, revealed "Non-restraint measures: Bed Alarm, Low Bed." There was no other documentation of safety measures in place for MR2 on this date.

2. Review of MR3 on July 8, 2011, at approximately 10:30 AM revealed a Morse Fall risk Assessment of 125, dated June 24, 2011. The fall risk indicated, " > 45 Fall Risk Assessment then place patient in Low bed with bed alarm and use of wheelchair alarm."

Daily progress/Narrative note for MR3 dated July 5, 2011, at 0300 indicated, " ...Please note that the bed alarm has been removed from this pt's bed. Patient is a fall risk and bed alarm is needed ... "

Observation in the dining room on July 8, 2011, at approximately 12:00 PM, revealed that MR3 was sitting in a wheelchair without an alarm attached to the alarm box.

Interview on with EMP16, on July 8, 2011, at approximately at approximately 10:45 AM confirmed that MR3 had an alarm on the chair, but it did not have an alarm box. Further interview revealed, " EMP1 was looking for alarms this morning, but they could not find them "

3. On July 7, 2011, at approximately 10:30 AM review of MR6 revealed the patient was admitted to the facility on June 17, 2011, with a Morse fall risk score of 65 (>45 = implement high risk precautions). The "Non-Restraint Interventions" form also completed on June 17, 2011, indicated that a low bed with alarm and wheelchair alarm were recommended as high risk fall precautions at this time. Nursing note dated June 17, 2011, 22:00 PM documented "...Pt confused, combative and verbally abusive. ...Fall mats in place, bed alarm in place, strongly recommend low bed - charge nurse advised."

Review of the IDD dated June 18, 2011, revealed "Non-restraint measures: 3 side rails." Nursing note 04:30 AM "...fall mat in place." There was no other documentation of safety measures in place for MR6 on this date.

Review of the Plan of Care for patient safety dated June 19, 2011, indicated that adequate fall precautions were not in place and that MR6 "May need a low bed."

Review of the IDD dated June 19, 2011, revealed "Non-restraint measures: [blank]." Nursing documentation for this date continued to indicate the patient was restless, climbing out of bed and a bed alarm was placed during the night. Nursing note for 6:00 PM revealed that the patient fell out of his chair while in the dining room, sustaining a laceration and hematoma to the face and head. There was no documentation that the patient's wheelchair alarm was in place and/or functioning at the time of the fall. During an interview on July 7, 2011, at 9:45 AM EMP3 stated the facility was recently made aware that MR6 sustained a fracture as a result of the fall on June 19, 2011.

Review of facility documents related to the above event indicated that a fall assessment was completed but the patient was not determined at risk.

During an interview on July 7, 2011, at 10:20 AM EMP2 stated " If they are using them [alarms], it should be documented on the record. "

4. On July 7, 2011, at 2:00 PM review of MR8 revealed the patient was admitted to the facility on June 16, 2011. Upon admission, the patient was identified as high risk for falls with a Morse fall risk score of 70. Documentation on June 16, 2011, indicated that a low bed with bed alarm and a wheelchair alarm were recommended. Incident report dated June 22, 2011, indicated that MR8 fell in his room but documentation was unclear as to whether the fall was from a bed or wheelchair.

On July 7, 2011, at approximately 2:05 PM MR8 was observed sitting in a wheelchair in his room. At the time of observation EMP8 confirmed that the patient did not use a wheelchair alarm when out of bed.

5. Review of MR9 on July 8, 2011, at 10:40 AM revealed the patient was admitted to the facility on May 5, 2011. Morse fall risk score was 125 (high risk) at the time of admission. A Non-Restraint Interventions form was completed at that time recommending that the patient use a low bed with bed alarm and a wheelchair alarm when out of bed. The IDD for May 5, 2011, indicated "Non-restraint measures: [blank]."

Nursing note dated May 6, 2011, 15:30 PM states "Pt. found on floor in room by dietary personnel...WC alarm/bed alarm order given." Upon review of the Doctor's Order Sheet dated May 6, 2011, at 17:30 PM an order had been written for a low bed, mat, bed alarm and chair alarm.

During an interview on July 8, 2011, at approximately 11:00 AM EMP1 confirmed, " Fall interventions should have been initiated for this patient immediately after admission. We need to find a way to get more safety equipment up to the unit so it's always at their fingertips when they [staff] need it.

6. On July 8, 2011, at 11:25 AM a review of MR10 revealed the patient was admitted to the facility on June 21, 2011. At the time of admission the patient had a Morse fall risk score of 95. Other assessment documentation indicated the patient " Moves non-stop - slow to focus. "

Review of a facility document indicated that on July 1, 2011, at 4:30 AM, " Pt. called to nursing station, saying she rolled out of bed. Went to room [MR10], found sitting beside bed, kneeling on knees, says she tried to untangle her blanket and rolled out onto knees. " The report further indicated that the patient was at high risk for falls but preventative measures were not in place at the time of the fall.

Continued review of MR10 did not reveal documentation to indicate why the recommended fall prevention precautions had not been initiated for this patient.

On July 8, 2011, at approximately 11:25 AM observation revealed that MR10 was not presently using a low bed or bed alarm.

During an interview on July 8, 2011, at approximately 11:30 AM EMP1 confirmed the above observation and stated " I can't think of a good reason why they [fall risk interventions] wouldn't be implemented if the patient meets the criteria for high fall risk. "

7. On July 8, 2011, at 12:05 PM review of MR11 revealed the patient was admitted to the facility on June 30, 2011. At the time of admission the patient had a Morse fall risk score of 70 indicating that high fall risk precautions should be implemented.

On July 8, 2011, at 12:20 PM EMP1 confirmed that MR11 was not using a wheelchair alarm for safety and there was no documentation to indicate why a wheelchair alarm was not used for this patient.

8. Review of MR14 on July 8, 2011, at approximately 11:00 AM revealed a "Non-Restraint Interventions" form dated June 27, 2011, which indicated, "Bed alarms...>45 Fall Risk Assessment then place patient in low bed with bed alarm and use wheelchair alarm. Interdisciplinary Plan of Care indicated, "IDA (Interdisciplinary Assessment) Morse Scale 115...High Risk Fall Precautions..."

Observation of MR14's bed on July 7, 2011, at approximately 1:20 PM, revealed that MR14 did not have a bed alarm on the bed. Further observation in the therapy room, at approximately 2:15 PM, revealed that MR14's wheelchair did not have a chair alarm attached to the wheel chair. EMP16 confirmed this observation at 2:15 PM.

Interview on with EMP1 on July 8, 2011, at approximately 9:30 AM, confirmed that there are missing bed and chair alarms. Further interview revealed, "I do not know where they are, we have enough alarms."

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure the provision of accurate and concise nursing records and reports which reflect the progress of the patient and contribute to the continuity of patient care for nine of 15 patients. (MR1, MR2, MR6, MR8, MR9, MR10, MR11, MR13 and MR15).

Findings include:

Review of facility policy, "Fall Prevention Program " revised May 18, 2010 revealed, "...Initial Post Fall Assessment First priority is to assess the patient for any obvious injuries and find out what happened. The information needed is: 1. Date/time of fall. 2. Patient's description of fall, what was the patient trying to accomplish, Where was the patient at the time of the fall (patient room, bathroom, common room, hallway, etc.) 3. Family/guardian and provider notification according to policy 4. Vital signs (temperature, pulse, respiration, blood pressure, orthostatic vital signs may be necessary) 5. Current medications...6. a. Injury b. comorbid conditions, c. Risk factors...d. Modified Morse Fall Assessment Other Factors: ...Environmental a) Bed in high or low position, b) Bed wheels locked, c) Wheelchair locked, d) Floor wet,....f) Call system and other monitors in working order...i) Area clear of clutter and other items...vi. Was the treatment intervention plan being followed? If not, why not? B. Documentation and follow-up Following the post-fall assessment and any immediate measure to protect the patient: 1. An incident report should be completed...2. A note should be entered into the patient record including the results of the post-fall physical assessment...5. Communicate to all shifts that a patient has fallen and is at risk to fall again. ..."

Review of facility policy "Assessment of Patient Needs/Identification of Patient Care Needs" revised/reviewed July 2010 revealed "Purpose: A. To provide optimal nursing care in accordance with individualized patient needs. ...Policy: The Healthsouth Rehabilitation Hospital of Sewickley Professional Nurse uses the nursing process to plan nursing care based on a documented assessment of individualized patient care needs. These needs are reassessed and evaluated beginning with admission throughout the inpatient stay and including discharge. ...C. ...4. The patient's medical record includes documentation of the following: ...b. identification of patient care needs c. nursing interventions and teaching to meet identified patient and significant other needs."
Review of facility policy "Low Bed Guidelines" revised/reviewed July 2009 revealed "...Guidelines: 1. The low bed is a restraint alternative. 2. If a patient's fall risk assessment is 45, unless contraindicated, the patient is recommended to be placed in a low bed with a bed alarm, and a wheelchair alarm should also be placed on the wheelchair."
1. Review of facility documents revealed that the patient of MR1 was found on the bathroom floor on June 3, 2011. Continued review of MR1, on July 8, 2011, at approximately 10:00 AM, revealed the record did not contain a a post fall physical assessment. Vital signs were obtained at 7:15 PM, but the event report was timed 18:45 (6:45 PM).

Interview with EMP3 on July 7, 2011, at approximately 9:00 AM, confirmed that MR1 did not include documentation of the exact time of the fall, the specific time the vital signs were taken, and who was with MR1 before and after the fall.

2. Review of facility documents revealed that the patient of MR2 was found on the floor on June 12, 2011, at 2 AM and had slid out of of the wheelchair on June 14, 2011, at 1:45 PM. Continued review of MR2, on July 8, 2011, at approximately 11:00 AM, revealed the record did not contain a a post fall assessment or any documentation that the events occurred.

Interview with EMP13 on July 8, 2011, at approximately 11:00 AM, confirmed there was no documentation of the use of a wheelchair alarm in the patient safety section of the Interdisciplinary Daily Documentation Daily Nursing Assessment for MR2.

Interview with EMP2 on July 11, 2011, at approximately 2:00 PM confirmed that there was no documentation in MR2 that the patient was found on the floor or slid out of the wheelchair on June 12, 2011, or June 14, 2011.

3. Review of MR15, on July 8, 2011, at approximately 11:00 AM, revealed a Daily Progress/Narrative note dated July 7, 2011, at 9:15 which indicated, "OT staff called unit and Code White called. Pt again aggressive needed to be restrained to stop pt from striking out at staff...." Further review of MR15 revealed that there were no orders for a restraint.

Interview with EMP1, on July 8, 2011, at approximately 11:00 AM revealed, "I was there for that incident and the patient was assisted to his chair not restrained... that documentation is incorrect."

4. On July 7, 2011, at approximately 10:30 AM a review of MR6 revealed the patient was admitted to the facility on June 17, 2011, and was determined to be at high risk for falls. The Non-Restraint Interventions form, also completed upon admission indicated that a low bed with alarm and wheelchair alarm were initiated for this patient.

Further review of MR6 revealed a nursing note dated June 17, 2011, 22:00 PM " ...Fall mats in place, bed alarm in place, strongly recommend low bed - charge nurse advised. "

A review of other facility documents indicated that the patient of MR6 fell from his chair on June 19, 2011. The document further indicated that a fall assessment was completed but the patient was not at risk for falls.

During an interview on July 8, 2011, at 10:30 AM, EMP1 confirmed the conflicting documentation regarding fall interventions implemented and the patient's fall risk status.

5. On July 7, 2011, at 2:00 PM, review of MR8 revealed the patient was admitted to the facility on June 16, 2011, and was determined to be at high risk for falls. The Non-Restraint Interventions form, also completed upon admission, indicated that a low bed with alarm and wheelchair alarm were initiated for this patient.

A review of other facility documents indicated that the patient fell in his room on June 22, 2011, but documentation did not indicate whether the fall was from a bed or wheelchair and did not indicate whether alarms were in place and/or functioning. Nursing note dated June 22, 2011, at 18:00 PM also did not indicate from where the patient fell or whether alarms were in place and/or functioning.

During an interview on July 7, 2011, at 2:05 PM EMP8 stated, " [MR8] doesn't use a wheelchair alarm, just a bed alarm. "

6. On July 8, 2011, at 10:40 AM review of MR9 revealed the patient was admitted to the facility May 5, 2011, and was determined to be at high risk for falls. The Non-Restraint Interventions form, also completed upon admission, indicated that a low bed with alarm and wheelchair alarm were initiated for this patient.

Nursing note dated May 6, 2011, at 15:30 revealed that the patient was " Found on floor in room ...WC alarm/bed alarm order given." Review of the IDD for May 6, 2011, revealed no documentation on the "Non-restraint measures" section of the form.

During an interview on July 8, 2011, at approximately 10:50 AM EMP1 confirmed the conflicting documentation regarding the implementation of fall reduction measures.

7. Review of MR10 on July 8, 2011, at 11:25 AM revealed the patient was admitted to the facility on June 21, 2011, and was determined to be at high risk for falls.

Facility documents dated July 1, 2011, indicated the patient "Rolled out of bed." The documentation further indicated that no fall precautions were in place at the time of the fall.

Further review of MR10 revealed there was no documentation as to why fall precautions were not implemented for the patient.

During an interview on July 8, 2011, at 11:25 AM EMP1 confirmed there was no documentation why the patient was not placed on fall precautions and stated, "If they [patients] meet the criteria, precautions should be in place or there should be documentation in the record to say why the plan was not implemented."

8. Review of MR11 on July 8, 2011, at approximately 12:00 PM revealed the patient was admitted to the facility on June 30, 2011, and was determined to be at high risk for falls. The Non-Restraint Interventions form, also completed on admission, indicated that a low bed with alarm and wheelchair alarm were initiated for this patient.

Review of the current Patient Care Kardex revealed the patient was not utilizing a wheelchair alarm. Continued review revealed there was no documentation in the record to indicate why MR11 was not utilizing a wheelchair alarm.

An observation on July 8, 2011, at 12:00 PM revealed MR11 did not have a wheelchair alarm in place.

During an interview on July 8, 2011, at 12:05 PM EMP1 confirmed the conflicting documentation in MR11 regarding use of a wheelchair alarm.

9. On July 8, 2011, at 2:30 PM a review of MR13 revealed the patient was admitted to the facility on May 23, 2011, and was determined to be at high risk for falls.

Facility documents dated June 14, 2011, 10:55 AM indicate that " Pt went to reach for dropped object on floor & lowered self to knees. A. Location of incident: OT clinic ...Event Details Questions: M. Fall risk assessment completed: Unknown. N. At the time of last assessment, was patient determined at risk? Unknown. "

Continued review of the MR13 revealed documentation by the Occupational Therapist indicating the patient participated in therapy at 10:00 AM and 1:30 PM on June 14, 2011. There was no documentation related to the above identified incident.

The nursing note dated June 14, 2011, 5:00 PM stated, "Pt found on floor several times today."

During an interview on July 8, 2011, at approximately 2:45 PM EMP1 confirmed, "If a patient event happened in the OT department they should have documented about it in their notes." EMP1 also confirmed there was only one facility report related to MR13 on June 14, 2011, stating, "If the patient fell more than once, there should have been separate reports."