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Based on record review and interview, the facility staff failed to develop and implement appropriate policies and procedures to ensure the safety of patients determined to require continuous 1 to 1 observation in 2 of 3 (Patients #1 and #9) patients with 1:1 observation needs in a total sample of 10 patient medical records reviewed.

Findings include:

Review of policy titled, "Patient Falls Program" Version 2 dated 09/05/2023 revealed, "Purpose: To identify patients at risk of falls so that appropriate interventions can be implemented ... Each patient shall be assessed to determine the need for patient-specific assessments and reassessments ... Patients assessed/reassessed as a risk for fall shall have said assessment/reassessment documented in the medical record. The medical record should also reflect documentation of interventions deployed to prevent falls."

A review of facility guidelines titled, "One to One Sitter Justification Guidelines" undated revealed, "Any care team member can request a sitter for a patient. The Sitter Request Evaluation Form must be filled out by the requester and turned in to the CNO (Chief Nursing Officer), DQM (Director of Quality Management), or CTO (Chief Therapy Officer) (or designee if all 3 are unavailable) ...If the evaluation warrants the sitter need, the designated approver will notify the requester as soon as possible. If a sitter is needed prior to approval, the supervisor should be notified immediately in order to provide staff who are able to be a sitter during the approval time. An order for a sitter must be placed on the patient chart ... Plan of care should address the need for a sitter and the plan for addressing or discontinuing the sitter prior to any level discharge. The team should decide the safety level needed for discontinuing the sitter per the patient assessment and safety trials as the patient condition improves or declines ... An order to change sitter levels or to discontinue the sitter should be placed after team agreement. An example would be a brain injury patient who has shown some improvement in condition during the stay but continues to require a sitter in the evening hours would need an order for the sitter for those hours."

Review of Patient #1's medical record revealed an admission date of 12/15/2023. Patient #1 had a fall on 01/2/2024 at 1:30 PM.

Review of Patient #1's medical record revealed a physician order for 1:1 sitter placed on 12/27/2023. Patient #1 suffered a fall on 01/02/2024 at 1:30 PM. Per the medical record review, there was no sitter in place at the time of the fall, despite the order remaining active at the time.

During an interview with Chief Executive Officer (CEO) B on 03/26/2024 at 12:15 PM, CEO B stated nursing staff determined Patient #1 no longer met criteria for a sitter on 12/30/2023 and the 1:1 observation was discontinued. The discontinuation order was not placed until after the fall on 01/02/2024 at 6:42 PM. The sitter justification forms were not considered part of the permanent medical record and were not available for review during the survey making it was difficult to determine whether ongoing 1:1 observation needs were assessed as per policy.

Review of Patient #9's medical record revealed an admission date of 03/11/2024. Patient #1 had a fall on 03/17/2024 at 7:00 AM.

Review of Patient #9's medical record revealed Patient #9 suffered a fall on 03/17/2024. Per medical record review, Patient #9 was provided 1:1 observation (sitter) from 03/12/2024 until 03/17/2024. There was no physician order for continuous 1:1 observation found.

During an interview with Regional Chief Nursing Officer (RCNO) I on 03/27/2024 at 12:08 PM, RCNO I stated nursing staff determined Patient #9 did meet criteria for a sitter, however stated "the scheduled sitter called in ill, and the facility was unable to find staff to provide the 1:1 continuous observation" for Patient #9. The sitter justification forms were not considered part of the permanent medical record and were not available for review during the survey making it was difficult to determine whether ongoing 1:1 observation needs were assessed as per policy. The facility did not determine or implement appropriate alternate methods to ensure Patient #9's safety. Patient #9 suffered a fall during the time that 1:1 continuous observation was not provided due to lack of staff.

Based on record review and interview, the facility staff failed to follow policy with documentation for 2 of 4 patient falls (Patient #1 and #9) and failed to establish, document, and follow guidelines for interventions for patients at high risk for falls for 2 of 4 patients (Patient #1 and 9) in a total universe of 10 medical records reviewed.

Findings include:

A review of facility policy Version 2, titled, "Patient Falls Program" reviewed 09/05/2023 revealed, "Purpose: To identify patients at risk of falling so that appropriate interventions can be implemented ... High Fall Risk: Morse Fall Risk 45 or more or other identified concerns by any team member. All standard and Medium level interventions plus additional interventions may be deployed to further prevent a fall including, but not necessarily limited to, the following: bed alarm and /or chair alarm, consider the need for safety surveillance, use of assistive devices for postural support, mobility, and/or ambulation, consider increasing the frequency of observation and assistance to the patient for care needs. Any additional measures identified by the interdisciplinary team that may benefit the patient, such as moving closer to the nurse's station when possible, or any other potential safety elements, such as mats by the bed. Documentation in the Medical Record- Patients assessed/reassessed as a risk for fall shall have said assessment/reassessment documented in their medical record. The medical record should also reflect documentation of interventions deployed to prevent a fall. If a fall occurs: Assess the patient for injury prior to moving. Notify physician and notify family member. Document the physical assessment and events in the chart and complete the post-fall assessment in the EMR (Electronic Medical Record). Conduct post fall assessment of the fall within 15 minutes of the fall and plan further interventions. An incident report should be completed and turned in to the quality department."

A review of facility guidelines titled, "One to One Sitter Justification Guidelines" undated revealed, "Any care team member can request a sitter for a patient. The Sitter Request Evaluation Form must be filled out by the requester and turned in to the CNO (Chief Nursing Officer), DQM (Director of Quality Management), or CTO (Chief Therapy Officer) (or designee if all 3 are unavailable) ...If the evaluation warrants the sitter need, the designated approver will notify the requester as soon as possible. If a sitter is needed prior to approval, the supervisor should be notified immediately in order to provide staff who are able to be a sitter during the approval time. An order for a sitter must be placed on the patient chart ... Plan of care should address the need for a sitter and the plan for addressing or discontinuing the sitter prior to any level discharge. The team should decide the safety level needed for discontinuing the sitter per the patient assessment and safety trials as the patient condition improves or declines ... An order to change sitter levels or to discontinue the sitter should be placed after team agreement. An example would be a brain injury patient who has shown some improvement in condition during the stay but continues to require a sitter in the evening hours would need an order for the sitter for those hours."

A review of Patient #1's medical record revealed an admission date of 12/15/2023. Patient #1 had a fall on 01/02/2024 at 1:30 PM.

A review of Patient #1's Physician orders beginning 12/27/2023 at 6:00 PM through 01/02/2024 at 6:42 PM revealed, "Sitter 1:1 Continuously".

A review of documentation in Patient #1's medical record and assignment sheets reveal that Patient #1 did not have a sitter on 01/02/2024 at 1:30 PM when Patient #1 had a fall. There was no evidence that a sitter was documented from 01/01/2024 at 6:30 PM through 01/02/2024 at 6:42 PM when the order was discontinued.

A review of Patient #1's medical record revealed assessments indicating Patient #1 no longer required a sitter based on criteria were not found in the medical record. Based on the facility's current sitter guidelines, the sitter request forms are not considered a permanent part of the medical record.

A review of Patient 1's "Incident Report" dated 01/02/2024 revealed, "Incident/Fall Date: 01/02/2024 Incident Time: 1:30 PM. Admission date 12/15/2023. CNO (Chief Nursing Officer) notified that patient had fallen. Interviewed the CNA (Certified Nursing Assistant) who shared [s/he] was at the nursing desk and could visualize [Patient #1]. Could see [her/him] lean forward and hit head on floor ... The sitter order is still documented and not dc/d (discontinued) over the weekend, however the patient has not had a sitter for the last couple of days per RN (Registered Nurse) assessment."

During an interview on 03/26/2024 at 12:15 PM, the medical record review findings were discussed with and confirmed by Chief Executive Officer (CEO) B who stated, "[Patient #1] had a 1:1 sitter beginning on 12/27/2024 however daily assessments determined [Patient #1] no longer required a sitter based on criteria."

During an interview on 03/26/2024 at 2:00 PM, Nurse Practitioner F stated when asked about Patient #1, "If a sitter was ordered [for Patient #1] I assume there was a sitter with [her/him]."

A review of Patient #1's "RN Progress Notes" revealed, on 01/02/2024 after the fall at 1:30 PM, there was no RN Progress Note documented of the fall in Patient #1's medical record. During an interview on 03/27/2024 at 1:45 PM, the medical record review findings were discussed with and confirmed by RN Supervisor E who stated there was no RN Progress Note documented addressing the fall on 01/02/2024.

A review of Patient #9's medical record revealed an admission date of 03/11/2024. Patient #9 had a fall on 03/17/2024 at 7:00 AM.

A review of Patient #9's Physician orders for 03/17/2024, there was no physician orders for a 1:1 sitter. Review of the medical record revealed evidence that assessments/care plan notes indicated Patient #9 met criteria for a sitter per policy and a sitter was provided and maintained continuously from 03/12/2024 through 03/17/2024 at 6:30 AM.

During an interview on 03/27/2024 at 12:08 PM, the medical record review findings were discussed with and confirmed by Regional Chief Nursing Officer (RCNO) I who stated [Patient #9] had a sitter since admission into the hospital, a sitter order should have been written in the medical record.

A review of Patient #9's "Incident Report" dated 03/17/2024 revealed, "Incident/Fall Date: 03/17/2024 Incident Time: 7:00 AM. Admission date 03/11/2024. Sitter left without signing out with RN (Registered Nurse), next sitter called in. When sitter left [s/he] did not turn on bed alarm and pt exited bed and fell. No plan was made with RN about how to handle lack of staff. Pt. is confused at baseline. Follow up/Resolution: Per incident review, NOC (night) shift sitter left at end of shift and did not put alarm on. Day shift sitter called in. Per HS (House Supervisor) report, there was no staff to assume sitter responsibilities. Patient exited bed and fell to floor. Patient was attempting to get to bathroom. No injury. HS implemented increased rounding for safety. MD (Medical Doctor) and family notified."

A review of Patient #9's "Rounding Documentation" dated 03/17/2024 revealed, rounding was completed by CNA V at "6:00 AM- sleeping, vitals 7:00 AM- (blank- not checked), 8:00 AM- sitting at the nurses station, 9:00 AM- (blank- not checked), 10:00 AM- bathroom/back in his chair, 11:00 AM- (blank- not checked), 12:00 PM-lunch in hallway with family, 1:00 PM- (blank- not checked), 2:00 PM- in bed, 3:00 PM- (blank- not checked), 4:00 PM-by window with the nurse, 5:00 PM- (blank- not checked), 6:00 PM- sitting at table in hallway." There was no documentation that rounding was increased prior to or after Patient #9's fall on 03/17/2024.

A review of Patient #9's "RN Progress Notes" revealed, on 03/17/2024 after the fall at 7:00 AM, there was no RN Progress Note documented of the fall.

During an interview on 03/27/2024 at 10:00 AM, the medical record review findings were discussed with and confirmed by Director of Quality C who stated there was no RN Progress Note documented addressing the fall on 03/17/2024 per policy.

During an interview on 03/27/2024 at 12:08 PM, the medical record review findings were discussed with and confirmed by Regional Chief Nursing Officer (RCNO) I who stated, "there was not a physician order for a 1:1 sitter, however it was determined that [Patient #9] needed a 1:1 sitter for safety. The night shift CNA (Certified Nursing Assistant) left at the end of the shift and did not turn the bed alarm on. The day shift CNA called in for the shift. Attempts were made to find a replacement but was not able to find anyone. After the fall, it was determined in the post fall huddle, rounding would be increased." When RCNO I was asked what the facility actions were following the fall investigation, RCNO I stated, "The fall investigation is not complete yet."

During an interview on 03/28/2024 at 1:02 PM, Nurse Practitioner F stated, "Our current process allows any caregiver to implement a sitter for safety purposes."