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Based on interview and record review, the facility failed to have an effective process in place to assure that each patient's representative is given information on the patient's health status, diagnosis, and prognosis.

The medical record of one (1) of four sampled discharged patients (Patient ID # 6) who sustained a fall with injury contained documentation of notification of " next of kin. "

Findings include:

TX 00176686

Review of Patient ID # 6 ' s clinical record reveled he was 83 years old and admitted to the facility on 04-20-2012 for continued IV antibiotic therapy. Review of Patient ID # 6 ' s History & Physical exam, dated 04-21-12 revealed a history that included Atrial Fibrillation, Deep Vein Thrombosis, Anxiety, Depression, Chronic Kidney Disease and Anemia.

Record review on 06-12-13 of nursing notes for Patient ID # 6: dated 04/27/13 (time 0100): pt transported to ( ) hospital...status post fall for observation. Dr. call all paper work filled out. Dr. notified along with administration. Pt has no family listed..."

Record review on 06-12-13 of facility incident report dated 04-27-12 read " fall: (untimed)... room 218, serious: laceration to head and right shoulder, alert verbal ...physician notified. " was family notified? " no family. " Pt sent to ( ) ER on 04-27-12 at 0130..."

Record review on 06-12-13 of physician progress note dated 4-27-12 read" status post fall: subdural hematoma.... head contusion.. "

Record review on 06-12-13 of results of CT brain performed on: 04-27-12: "large right sided subdural hemorrhage with associated mass effect and midline shift... "

Review of Patient ID # 6 ' s admission face sheet information: no " next of kin " was listed in the space for this information. There was a form in the admission section titled: " Authorization To Release & Communicate With family Members & Friends " -patients name and address was listed but no listing of family/friends in which to " receive communications regarding my healthcare... "

Review of facility ' s 4-page Preadmission Screening Summary, dated 04-20-12, section titled: Admission Information: Next of Kin/Responsible Party: (son's full name was listed as well as his telephone number) .. "

Review of Nutrition Progress Notes, dated 04-24-12 (0950): spoke with pt ' s son by phone this a.m. .... "

On 06-12-13 at 4:00 p.m. interview with Chief Clinical Officer (CCO) ID #2, she stated the facility policy and her expectation was the family should have been notified after Patient ID # 6 fell and was taken to the hospital. She went on to say it was the admission clerk's responsibility to place the " next of kin " name and telephone number on the admission face sheet. If this was not possible at time of admission, the admission clerk should have followed up.

The CCO (ID # 2) acknowledged the name and phone number for the " next of kin " of Patient #ID # 6 was available in several places in the record. The nurse should have telephoned when the fall and subsequent hospital transfer occurred.

Review of facility policy titled " Unanticipated Outcomes, dated 5/2011, read: " it is the policy ...to comply with laws, regulations, and standards governing the disclosure of outcomes of care, including unanticipated outcomes to patients, surrogate decision makers, and patient representatives, as appropriate ... ....an Unanticipated Outcome : an outcome that the care giving personnel did not expect to occur ...that currently has, or may in the future have, a significant impact on patient care, treatment, or well-being ...Patients or when appropriate ...,the patient representative, shall be informed about the outcomes of care, including unanticipated outcomes.. "

Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) supervised and evaluated the care for one (1) of four sampled discharged patients (Patient ID # 6) who sustained a fall with injury. A RN failed to ensure:

? a physician order for a low bed was implemented for Patient ID # 6; and

? consideration and implementation of additional identified fall prevention measures.

This deficient practice likely contributed to the injury sustained by Patient ID # 6 and could potentially impact all of the inpatients assessed as being high risk for falls.

Findings include:

TX # 00176686

Record review on 06-12-13 of Patient ID # 6 ' s clinical record reveled he was 83 years old and admitted to the facility on 04-20-2012 for continued IV antibiotic therapy. .His medical history included: Atrial Fibrillation, Deep Vein Thrombosis, wound infection/polymicrobial, MRSA bacteremia, chronic kidney disease and anemia.

Order for low bed:

Record review on 06-12-13 of Patient #6 ' s clinical record revealed a physician order dated 04-21-12 that read: " ...overlay air mattress, low bed (multiple falls ... "

Further review of the clinical record failed to reveal the low bed had been provided and was put in use.

Interview on 06-12-13 at 3:50 p.m. with the Director of Quality Management (ID # 3) she acknowledged the low bed had not been provided as ordered by the physician.

Additional fall precautions:

Record review on 06-12-13 of Patient # 6 ' s nursing admission assessment revealed that on 04-20-12 " Safety/Fall Risk Prevention...Fall Risk " was completed. Check marks were placed on " fall risk band " and " refer to plan of care. " Patient ID # 6 was assessed on admission with 39 total points, which indicated he was high risk for falls. The form then indicated he would be placed on all interventions for Protocol A (low to moderate risk -0-9 points) and those interventions on Protocol B (points above 10-high risk).High risk interventions included: consider bed alarm or landing strip, move pt., near nurses ' station, involve the family for assistance during high risk times, consider sitter, low bed,,,,

Review of daily nurse ' s notes/ flow sheets from 04-20-12 to 04-26-12 revealed Patient # 6 was assessed each shift for fall risk by the nurses. Review of each nursing assessment each shift for this time period revealed Patient # 6 was assessed as " high risk " for falls.

Further review failed to reveal documentation of any fall prevention measures implemented for Patient ID # 6 for the time period 04-20-12 to 04-25-12 on either shift.

Record review on 06-12-13 of nursing notes for Patient ID # 6: dated 04/27/13 (time 0100): " pt transported to ( ) hospital...status post fall for observation. Dr. call ..all paper work filled out. Dr. notified along with administration. Pt has no family listed..."

Record review on 06-12-13 of facility incident report dated 04-27-12 read " fall: (untimed)... room 218, serious: laceration to head and right shoulder, alert verbal ...physician notified ...Pt sent to ( ) ER on 04-27-12 at 0130..."

Record review on 06-12-13 of physician progress note dated 4-27-12 read" status post fall: subdural hematoma.... head contusion... " Record review on 06-12-13 of results of CT brain performed on: 04-27-12: "large right sided subdural hemorrhage with associated mass effect and midline shift... "

Review of Fall Prevention Protocol B (points above 10-high risk). Read " High risk interventions included: consider bed alarm or landing strip, move pt., near nurses ' station, involve the family for assistance during high risk times, consider sitter, low bed,,,, "

Further review of the clinical record failed to reveal documentation that Patient # 6 had a bed alarm, low bed, landing strip, sitter, or any discussion with family about obtaining their assistance to prevent falls.

Interview on 06-12-13 at 3:50 p.m. with the Director of Quality Management (ID # 3) she
Stated the facility had conducted a Root Cause Analysis (RCA). She acknowledged that facility record review determined Patient # 6 had been assessed as high risk for falls, but only a few of the fall precautions available had been implemented. " Low bed had been checked but not implemented. "