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Based on document review and interview, the nurse executive failed to ensure that nursing staff follow established policy/procedure for falls prevention for 1 of 10 closed medical records reviewed.

Findings:

1. Policy/procedure PolicyStat ID: 853318, Falls Prevention, revised/reapproved 06/2014 indicated:
A. page 3: C. Documentation should be entered in the medical record indicating the Low and High Risk Interventions are in place.
B. page 4 : 8. Staff will maintain eye contact with all high risk patients up to bathroom, bedside commode and when transported.

2. Review of patient 1's medical record (MR) on 1/25/17 at approximately 1200 hours lacked documentation of high risk fall interventions in place specifically, staff maintaining eye contact with patient 1 on 12/28/16 while patient was in the bathroom. Review of Care/Assessment Flow Sheets for dates including 12/15/16 through 1/20/17 indicated a Fall Risk Assessment was completed 2 times daily per shift assessing patient as high risk for falls. Review of patient 1's MR indicated patient fell on 12/28/16 at 1845 hours fracturing his/her right hip.

3. On 1/25/17 at approximately 1300 hours, staff P4 (Manager, Organizational Excellence) was interviewed and confirmed patient 1 was assessed to be high risk for falls and required an assist of 1 person plus walker to ambulate and toilet. Staff P4 confirmed patient 1 fell in the bathroom on 12/28/16. Staff P4 confirmed staff P2 (Patient Care Tech [PCT]) left patient 1 unattended in the bathroom on 12/28/16 at the time of the fall. Staff P4 confirmed patient 1 was out-of-sight of staff P2 at the time of patient's 1 fall in the bathroom on 12/28/16. Staff P4 confirmed facility staff did not follow policy/procedure for falls prevention.