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Based on record review and interview, the staff failed to follow their policies and procedures by failing to obtain vital signs and neurology (neuro) checks after an unwitnessed fall in 2 of 2 patients with unwitnessed falls in a total of 10 medical records reviewed.

Findings include:

Record review of policy titled Fall Prevention and Risk Assessment #PC195, dated 3/08/2022 Page 5, 7. f. revealed "If the patient has an unwitnessed fall and has hit head or you can not verify they did not hit head nursing is to document vital signs and neuro checks every 15 minutes for 1 hour, then every 30 minutes for 1 hour."

Patient #2 was a 65-year-old admitted 10/14/2021 with post subarachnoid hemorrhage (brain bleed) and debility admitted for teaching, monitoring, and rehabilitation. Patient #2 had an unwitnessed fall on 10/30/2021 at 9:00 AM. Vital signs were documented post fall but there were no vitals signs or neuro checks every 15 minutes for an hour. Patient #2 was transferred to the Emergency Department 10/30/2021 at 10:26 AM.

Patient #8 was a 51-year-old admitted 5/12/2022 with a history of intraventricular hemorrhage (brain bleed) for remediation of deficits (re-learning of activities of daily living). On 5/21/2022 at 4:34 PM Patient #8 had an unwitnessed fall, found face down strapped into the "space chair." Vital signs were taken at 4:35 PM, 4:51 PM, and 5:13 PM (7 minutes late) and then at 9:50 PM (4 hours and 37 minutes late). An order for 1:1 supervision was obtained and started after the fall.

On 6/02/22 at 2:45 PM during interview with Chief Nursing Officer (CNO) C while reviewing Patient #2 and Patient #8's medical records, CNO stated there are "opportunities for improvement."

Based on record review and interview, the facility failed to ensure patient care equipment is maintained in a manner to ensure the safety of patients by failing to track equipment malfunctions in 2 of 2 equipment failures of patient care equipment (Patient #1 & #2) in a total of 10 patient medical records reviewed who used patient care equipment.

Findings include:

Review of policy titled "Maintenance Frequencies" #EC.02.04.01 EP 4 dated 11/23/2021 under Equipment malfunctions, Patient Care Equipment revealed When a malfunction is evident the following steps shall be taken: A. Double check procedure technique to ascertain whether there is a true malfunction or a procedural error. B. If the malfunction continues to occur, complete a work order as much information on how the device is defective."

Patient #1's medical record review revealed Patient #1 was a 74-year-old admitted 1/01/2022 for education and instruction with adjustment to right below the knee amputation (BKA). Patient #1 was on a flotation bed mattress. Nursing note dated 1/10/2021 at 11:45 PM revealed "Bed control not working." Nursing note on 1/11/2022
at 10:15 AM revealed "fixed bed issues."

Record review of Incident Report #15929 4074 for Patient #1, created 1/11/2022, under narrative revealed "Plant Ops (Operator) assessed the bed and found it functional." There was no evidence that adjustments were made to the equipment or if it was a staff procedural error.

Patient #2's medical record review revealed Patient #2 was a 65-year-old admitted 10/14/2021 with post subarachnoid hemorrhage (brain bleed) and debility admitted for teaching, monitoring, and rehabilitation. Patient #2 had an unwitnessed fall on 10/30/2021 at 9:00 AM and was transferred to the Emergency Department 10/30/2021 at 10:26 AM.

Record review of Quality Coaching Fall Huddle Tool dated 10/30/2021 for Patient #2 under What accounted for the difference in what was expected and what happened, revealed "belt alarm failure." Under Follow-up revealed "*take
equipment out of service." There was no evidence of a work order being completed.

On 5/31/2022 at 1:18 PM during interview with Plant Operator K, Operator K stated most complaints about patient equipment are "user error," and are fixed at the time of the request, and are not logged or tracked. When asked if a faulty alarm or a broken bed would have a work order in their system for tracking and trending of equipment errors, K stated "generally speaking, yes."

On 6/01/2022 at 2:18 PM during interview with Director of Quality F, when questioned if all patient care equipment issues were logged to track and trend equipment failure, Director F stated "you have a point, I'm not sure."

On 6/02/2020 at 1:38 PM during interview with CNO C, CNO C stated there was no report for replacement of the flotation mattress pad if it would have been replaced and confirmed there were no work-orders for Patient #1's bed or Patient #2's chair alarm, which would be expected if any repairs were completed.