HospitalInspections.org

Based on document review and interview, the facility failed to ensure the patient was involved in care planning and treatment (see tag 131), failed to failed to provide an emotionally safe environment for 1 of 1 patient with a language barrier (see tag 144), and failed to ensure staff assigned to patient care received restraint and seclusion training upon hire (see tag 196).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Patients Rights were promoted.

Based upon document review, observation and interview, the facility failed to follow its staffing matrix and ensure adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and other personnel were available to provide care to all patients for 1 of 10 medical records (MR) reviewed (patient #s 4) (see tag 392), failed to document fall risk precautions, implement fall risk precautions, update and/or initiate care plans related to falls, failed to utilize non-pharmacological interventions prior to psychotropic injections, failed to complete incident reports for all falls and failed to complete documentation on incident reports completed (see tag 395), failed to maintain current and accurate care plans (see tag 396), and failed to ensure staff assigned to patient care had specialized training and/or orientation and failed to ensure staff were educated on current fall risk policy for all current staff members (see tag 397).


The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Nursing Services provided quality health care in a safe environment.



29550

Based on document review and interview, the facility failed to ensure the patient was involved in care planning and treatment for 1 of 1 patients with language barrier.

Findings include;

1. Review of patient #8 medical record indicated the following:
(A) He/she was admitted on 11/20/17.
(B) The medical record indicated he/she spoke only Korean.
(C) The medical history and physical dated 11/21/17 stated under chief complaint "unable to understand", review of systems "unable to communicate (known error), under physical exam oropharynx not visualized as the patient would not open mouth completely.
(D) The comprehensive psychiatric evaluation dated 11/21/17 states on page 1 "Patient only speaks Korean, so could not assess. (He/she) was pleasant but unable to cooperate." Page 3 states "Unable to assess" for orientation. The insight and judgement were documented as poor and the intellectual assessment was below average, however unable to determine how the determinations were made if the patient was documented as speaking only Korean and unable to cooperate with the exam.

2. Staff member #A5 (Regional Clinical Director) verified the medical record information at 2:30 p.m. on 12/6/17.




29550

Based on document review and interview, the facility failed to provide an emotionally safe environment for 1 of 1 patient with a language barrier.

Findings include;

1. Review of patient #8 medical record indicated the following:
(A) He/she was admitted on 11/20/17.
(B) The record indicated the patient spoke only Korean.
(C) The comprehensive psychiatric evaluation documented 11/21/17 indicated under history of present illness that the provider could not assess due to patient only speaking Korean.
(D) The admission history and physical dated 11/21/17 indicated under chief complaint that the patient could not be understood.
(E) Physician progress notes dated 11/22/17 indicated under chief complaint that it could not be assessed because the patient only spoke Korean.
(F) Physician progress notes dated 11/28/17 indicated the patient was unable to specify complaint due to language barrier.
(G) The patient received IM (intramuscular) injections of Thorazine due to agitation on 11/21/17 and 11/22/17, however staff were unable to communicate with the patient to assess why the patient was upset prior to giving the psychotropic medication.
(H) Nurses notes dated 11/23/17 at 0945 hours stated "Pt can be combative with care. Cannot understand pt due to speaking korean."
(I) Nurses notes dated 11/26/17 at 1405 hours state "Pt teary. Unable to understand why due to language barrier..."
(J) An order was not written until 11/27/17 at 10:55 a.m. to use interpreter services for the patient.

2. Staff member #A5 (Regional Clinical Director) verified the medical record information at 2:30 p.m. on 12/6/17.


29550

Based on document review and interview, the facility failed to ensure staff assigned to patient care received restraint and seclusion training upon hire for 1 of 5 personnel files reviewed (N5).

Findings include;

1. Facility policy titled "STAFF ORIENTATION AND TRAINING FOR RESTRAINT AND SECLUSION" last reviewed/revised 2/17 states on page 1: "During hospital orientation, the initial restraint and seclusion competency is completed, prior to participating in restraint use and then revisited."

2. Review of staff member #N5 (Certified Nursing Assistant with hire date of 10/16/17) personnel file lacked documentation of training restraints and seclusion.

3. Staff member #A8 (Corporate Administrator) verified the above in interview beginning at 1:30 p.m. on 12/6/17.

Based upon document review and interview, the facility failed to follow its staffing matrix and ensure adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and other personnel were available to provide care to all patients for 1 of 10 medical records (MR) reviewed (patient #s 4).

Findings include:

1. Review of the facility Staffing Matrix (effective 11/27/17) called for a total of 3 licensed nursing personnel consisting of three RNs, or two RNs and one LPN, or one RN and two LPNs for a total of three licensed nursing personnel and called for a total of 3 CNAs for day shift and night nursing personnel for a census of 17 to 22 patients.

2. Review of the One Week Staffing Pattern Worksheet for 11/26/17 through 12/2/17 provided by staff member #A3 (Director of Nursing) indicated a census of 22 patients on 12/1-2/17 and indicated the 12/1/17 and 12/2/17 day shifts were staffed with 1 RN, 2 LPNs and 3 CNAs and the 12/1/17 night shift was staffed with 3 RNs and 3 CNAs.

3. Review of the policy/procedure Staffing - Nursing (revised 9-17) indicated the following: "If a patient's condition requires special precautions, i.e., suicide precautions, the Physician will write an order identifying the special precautions required ... 1:1 nursing observation with staff (staff will be assigned to only that one patient ..."

4. Review of the patient #4 MR indicated orders on 12/1/17 at 1000 hours for 1:1 staffing and no MR documentation including nurses notes, Patient Monitoring Rounds or Patient Care Observation Record indicated the 1:1 staffing was implemented as ordered.

5. Review of the One Week Staffing Pattern Worksheet for 11/26/17 through 12/2/17 and December 2017 Staffing Calendar and Agency Staffing Sign In sheet failed to indicate additional nursing staff were assigned to provide care in response to the Physician orders.

6. Staff members #A2 (Administrator) and #A3 (Director of Nursing) confirmed the medical record for patient #4 indicated orders on 12/1/17 at 1000 hours for 1:1 staffing and confirmed the Weekly Staffing Worksheet, December 2017 Staffing Calendar, Agency Staffing Sign In Sheet and patient MR lacked documentation indicating that additional nursing staff were on duty on 12/1-2/17 to provide care in response to the order for 1:1 staff in interview at 3:10 p.m. on 12/6/17.

Based on document review, observation and interview, the registered nurse failed to supervise and evaluate the care being provided to patients for 8 of 10 patients (patients #2, 3, 5, 6, 7, 8, 9, and 10)

Findings include;

1. Facility policy titled "FALL PREVENTION PROTOCOL" last reviewed/revised 9/2017 indicated under interventions for low risk for falls interventions including, but not limited to, use a chair alarm when up in chair, bed in low position and bed upper rails in up position. The policy indicates that for a high risk for falls you use all low risk interventions plus: a) yellow wrist band on the patient.....d) Safe sitter/1:1

2. Document titled "POST FALL ASSESSMENT FORM" (part of incident report packet) indicated patient #3 had a fall on 12/3/17.

3. Facility policy titled INCIDENT REPORTS" last reviewed/revised 3/2017 states "An Incident Report should be competed immediately when an incident occurs."

4. Facility policy titled "GENERAL MEDICATION ADMINISTRATION" last reviewed/revised 5/2016 states on page 2: "12. PRN injectable medications are given as a last resort intervention in emergent situations when there is an imminent danger to self or others and when non-pharmacological interventions have been exhausted."

5. Review of patient 2 medical record indicated the following:
(A) Admission orders written on 11/20/17 at 1915 hours indicated patient was a high fall precaution.
(B) Fall Risk Assessment on 12/3/17 and 12/4/17 had high risk fall scores of 107 on all four shifts.
(C) Nursing Daily Assessment, fall precaution was not circled on 12/3/17 at 0100 hours and again on this date without a time documented, and on 12/4/17 at 0035 hours.
(D) Patient Care Observation Record lacked documentation of implementation of a fall risk indicator band and chair alarm during the day shift on 12/1/17 and 12/3/17 and implementation of a chair alarm during the day shift on 12/4/17.

6. Review of patient #3 medical record indicated the following:
(A) The patient was assessed as a high risk for falls.
(B) The nurses notes lacked documentation that the patient had a fall, circumstances leading to the fall, notifications to family and physician after the fall on 12/3/17.
(C) The medical record lacked documentation that the patient was placed on 1:1 after assessed as high risk for falls.
(D) The medical record lacked documentation of chair alarm use on 11/30/17 both shifts, 12/1/17 dayshift, 12/2/17 dayshift, and 12/3/17 both shifts.
(E) The medical record indicated that an order was written for Thorazine 50 mg po (by mouth) x1 now on 12/3/17 at 2100 hours for aggressive behavior and an order was written for Thorazine 37.5 mg IM (intramuscular) x1 on 12/4/17 at 1745 hours for aggression. The medical record lacked documentation of interventions or alternative techniques attempted prior to use of the antipsychotic medication.

7. Review of patient #4 MR indicated the following:
(A) Admission orders on 11/17/17 at 1550 hours for high fall precautions
(B) The patient experienced a fall on 11/25/17 at 0305 hours after awakening and rising out of a chair in the day room and the nurses notes indicated a chair alarm was not in use prior to the fall event.
(C) The Patient Care Observation Record lacked documentation of a yellow fall risk indicator band, yellow non-skid slippers or use of a chair alarm during the day shift on 11/26/17, 11/28/17 or 11/29/17.
(D) The MR indicated orders on 12/1/17 at 1000 hours for 1:1 staffing and no MR documentation including nurses notes, Patient Monitoring Rounds, Patient Care Observation Record or Treatment Plan indicated the 1:1 staffing was implemented as ordered.
(E) The Patient Care Observation Record lacked documentation of a yellow fall risk indicator band, yellow non-skid slippers or use of a chair alarm during the day shift on 12/2/17 by the Certified Nursing Assistant, staff member N11 after the staff completed Fall Prevention re-education on 11/30/17.

8. Review of patient #5 medical record indicated the following:
(A) The patient was admitted on 11/20/17 at 1500 hours and sustained a fall on 12/4/17 at 1805 hours.
(B) Fall Risk Assessment on 11/21/17 had a low risk fall score of 77 and on 12/4/17 had high risk fall score of 93.
(C) The nursing Daily Assessment forms lacked documentation that fall precaution were in place on 11/30/17 at 1345 hours.
(D) The Patient Care Observation Record lacked documentation of a fall risk indicator band, chair alarm, side rails x2, and low bed position during the day and night shifts on 11/20/17, a fall risk indicator band, a chair alarm, side rails x2, and low bed position during the day shift on 12/2/17, and a fall risk indicator band, a chair alarm, side rails x2, and low bed position during the day shift on 12/3/17.

9. Review of patient #6 medical record indicated the following:
(A) The patient was assessed as a high risk for falls.
(B) The medical record lacked documentation that the patient was placed on 1:1 after being assessed as high risk for falls.
(C) The medical record lacked documentation of chair alarm use on 11/25/17, 11/27/17 and 11/28/17 night shift.

10. Review of patient #7 medical record indicated the following::
(A) He/she was admitted on 11/8/17 at 1515 hours and sustained a fall on 11/27/17 at 1525 hours.
(B) The Fall Risk Assessment on 11/8/17 had a high risk fall score of 109 and on 11/27/17 had high risk fall score of 115.
(C) The Patient Care Observation Record lacked documentation of a chair alarm during the day shift on 12/1/17, 12/3/17 and 12/5/17.

11. Review of patient #8 medical record indicated the following:
(A) The patient was assessed as high risk for falls.
(B) The medical record lacked documentation that the patient was placed on 1:1 after being assessed as high risk for falls.
(C) The medical record lacked documentation of chair alarm use on 12/1/17 and 12/2/17 dayshift 12/3/17 and 12/4/17 both shifts.
(D) The physician progress notes dated 11/27/17 at 1310 hours stated "S/P (status post) fall left side no evidence of injury..." The medical record lacked any other documentation related to a fall. The nurses notes and daily nursing assessments lacked documentation that the patient had a fall.
(E) An order was written on 11/21/17 at 1815 hours for Thorazine 12.5 mg IM (intramuscular) now for increased agitation. An order was written on 11/22/17 at 1807 hours for Thorazine 12.5 mg IM now for agitation and aggression. The medical record lacked documentation of interventions or alternative techniques attempted prior to use of the antipsychotic medication. Additionally, the patient spoke only Korean and the medical record indicated in the nurses notes as well as physician documentation that the patient could not be understood due to language barrier. An interpreter service was not documented as sought until an order was written for such on 11/27/17 at 10:55 a.m.

12. Review of patient #9 medical record indicated the following:
(A) Physician orders on admission dated 11/16/17 at 1756 hours indicated patient was a low fall precaution.
(B) Fall Risk Assessment on 11/16/17 had a low risk fall score of 76.
(C) Patient Care Observation Record lacked documentation of a chair alarm during the day shift on 12/1/17 and 12/2/17.

13. Review of patient #10 medical record indicated the following:
(A) He/she was admitted on 11/1/17 at 2250 hours and sustained a fall on 11/19/17 at 0700 hours.
(B) Physician orders on admission dated 11/1/17 at 2250 hours indicated patient was a high fall precaution.
(C) Patient Care Observation Record lacked documentation of a chair alarm during the day shift on 11/20/17, 12/2/17 and 12/3/17 and lacked documentation of a fall risk indicator band and a chair alarm during the day shift on 11/22/17.

14. Review of incident reports indicated the following:
(A) An incident report for fall on 12/3/17 at 1120 hours for patient #4, under the Reviewed by Supervisor and Reviewed by Facility Nurse Leader sections on pg. 2 lacked documentation indicating the Director of Nursing, staff A3 had reviewed the fall event documentation.
(B) An incident report for fall on 12/4/17 at 1805 hours for patient #5, under the notification section on pg. 2 had 12/4/17 for the notification of the RN Supervisor, but lacked a time and whether or not it was verbal or written notification. Also had 12/4/17 at 1852 hours for the notification of the Director of Nursing, but lacked whether or not it was verbal or written notification.
(C) An incident report for fall on 11/27/17 at 1525 hours for patient #7, under the notification section on pg. 2 lacked a date, time and whether or not it was verbal or written notification for the RN Supervisor. Also had 11/27/17 for the notification of the Director of Nursing, but lacked the time.
(D) No documentation of an incident report for patient #8 and a fall on 11/27/17.
(E) An incident report for fall on 11/19/17 at 0700 hours for patient #10, under the notification section on pg. 2 lacked a date, time and whether or not it was verbal or written notification for the RN Supervisor. Also had 11/19/17 for the notification of the Director of Nursing, but lacked the time.


15. During facility tour beginning at 12:00 p.m. on 12/6/17, patient #3 and patient #8 were observed without a chair alarm or 1:1 sitter.

16. Staff member #A5 (Regional Clinical Director) verified the medical record information for patients 3, 6, and 8 at 2:30 p.m. on 12/6/17.

17. Staff member #A2 (Administrator) verified the medical record information for patients 2, 5, and 10 at 2:10 p.m. on 12/6/17.



29550

(D) The Patient Care Observation Record lacked documentation of a fall risk indicator band, chair alarm, side rails x2, and low bed position during the day and night shifts on 11/20/17, a fall risk indicator band, a chair alarm, side rails x2, and low bed position during the day shift on 12/2/17, and a fall risk indicator band, a chair alarm, side rails x2, and low bed position during the day shift on 12/3/17.

9. Review of patient #6 MR indicated the following:
(A) The patient was assessed as a high risk for falls.
(B) The MR lacked documentation that the patient was placed on 1:1 after being assessed as high risk for falls.
(C) The MR lacked documentation of chair alarm use on 11/25/17, 11/27/17 and 11/28/17 night shift.

10. Review of patient #7 MR indicated the following::
(A) He/she was admitted on 11/8/17 at 1515 hours and sustained a fall on 11/27/17 at 1525 hours.
(B) The Fall Risk Assessment on 11/8/17 had a high risk fall score of 109 and on 11/27/17 had high risk fall score of 115.
(C) The Patient Care Observation Record lacked documentation of a chair alarm during the day shift on 12/1/17, 12/3/17 and 12/5/17.

11. Review of patient #8 MR indicated the following:
(A) The patient was assessed as high risk for falls.
(B) The MR lacked documentation that the patient was placed on 1:1 after being assessed as high risk for falls.
(C) The MR lacked documentation of chair alarm use on 12/1/17 and 12/2/17 dayshift 12/3/17 and 12/4/17 both shifts.
(D) The physician progress notes dated 11/27/17 at 1310 hours stated "S/P (status post) fall left side no evidence of injury..." The MR lacked any other documentation related to a fall. The nurses notes and daily nursing assessments lacked documentation that the patient had a fall.
(E) An order was written on 11/21/17 at 1815 hours for Thorazine 12.5 mg IM (intramuscular) now for increased agitation. An order was written on 11/22/17 at 1807 hours for Thorazine 12.5 mg IM now for agitation and aggression. The MR lacked documentation of interventions or alternative techniques attempted prior to use of the antipsychotic medication. Additionally, the patient spoke only Korean and the MR indicated in the nurses notes as well as physician documentation that the patient could not be understood due to language barrier. An interpreter service was not documented as sought until an order was written for such on 11/27/17 at 10:55 a.m.

12. Review of patient #9 MR indicated the following:
(A) Physician orders on admission dated 11/16/17 at 1756 hours indicated patient was a low fall precaution.
(B) Fall Risk Assessment on 11/16/17 had a low risk fall score of 76.
(C) Patient Care Observation Record lacked documentation of a chair alarm during the day shift on 12/1/17 and 12/2/17.

13. Review of patient #10 MR indicated the following:
(A) Admission orders dated 11/1/17 at 2250 hours for high fall precautions.
(B) Patient #10 sustained a fall on 11/19/17 at 0700 hours.
(C) Patient Care Observation Record lacked documentation of a chair alarm during the day shift on 11/20/17, 12/2/17 and 12/3/17 and lacked documentation of a fall risk indicator band and a chair alarm during the day shift on 11/22/17.

14. Review of incident reports indicated the following:
(A) An incident report for fall on 12/3/17 at 1120 hours for patient #4, under the Reviewed by Supervisor and Reviewed by Facility Nurse Leader sections on pg. 2 lacked documentation indicating the Director of Nursing, staff A3 had reviewed the fall event documentation.
(B) An incident report for fall on 12/4/17 at 1805 hours for patient #5, under the notification section on pg. 2 had 12/4/17 for the notification of the RN Supervisor, but lacked a time and whether or not it was verbal or written notification. Also had 12/4/17 at 1852 hours for the notification of the Director of Nursing, but lacked whether or not it was verbal or written notification.
(C) An incident report for fall on 11/27/17 at 1525 hours for patient #7, under the notification section on pg. 2 lacked a date, time and whether or not it was verbal or written notification for the RN Supervisor. Also had 11/27/17 for the notification of the Director of Nursing, but lacked the time.
(D) No documentation of an incident report for patient #8 and a fall on 11/27/17.
(E) An incident report for fall on 11/19/17 at 0700 hours for patient #10, under the notification section on pg. 2 lacked a date, time and whether or not it was verbal or written notification for the RN Supervisor. Also had 11/19/17 for the notification of the Director of Nursing, but lacked the time.

14. During facility tour beginning at 12:00 p.m. on 12/6/17, patient #3 and patient #8 were observed without a chair alarm or 1:1 sitter.

15. Staff member #N13 (Licensed Practical Nurse) confirmed that patient #3 and patient #8 were observed without a chair alarm of 1:1 sitter.

16. Staff member #A3 (Director of Nursing) confirmed the Incident Report documentation dated 12/3/17 at 1120 hours for patient #4 failed to indicate they had completed the follow-up section of the report by the time of interview on 12/5/17 at 1440 hours.

17. Staff member #A5 (Regional Clinical Director) verified the MR information for patients 3, 6, and 8 at 2:30 p.m. on 12/6/17.

16. Staff member #A2 (Administrator) verified the MR information for patients 2, 5, and 10 at 2:10 p.m. on 12/6/17.

Based on document review and interview, nursing services failed to maintain current and accurate care plans for 7 of 10 MR (medical records) reviewed (patients #2, 3, 4, 5, 6, 8 and 10)

Findings include;

1. Facility policy titled "ASSESSMENT-FALLS" last reviewed/revised 1/2017 states on page 2: "6. Update plan of care with additional precautions."

2. Facility policy titled "TREATMENT PLAN" last reviewed/revised 9/2017 states on page 1: The needs, strengths, preferences and goals of the patient are identified based on the screening and assessment, and are used in the plan for care, treatment or services." and Goals and objectives will be reevaluated and, as necessary, revised based on changes in the patient's condition, problems, needs and responses to care, treatment and services." Page 2 states "The treatment plan shall be reviewed and updated as frequently as clinically indicated by the patient's anticipated length of stay and treatment issues, but at a minimum, the treatment plan is to be reviewed by 7 days after the Plan of Care, and 7 days thereafter."

3. Review of an incident report dated 12/3/17 at 2330 hours indicated patient #3 had a fall and was placed in a fall chair (foam chair) post fall.

4. Review of patient #2 MR lacked documentation of a weekly update to the fall treatment plan per policy.

5. Review of patient #3 MR lacked documentation that the care plan was updated to reflect the use of the foam chair. The care plan document had a section to check if patient was placed in foam chair, however the section was left blank.

6. Review of patient #4 MR indicated orders on 11/29/17 at 1110 hours for 1:1 staffing and lacked documentation indicating the Treatment Plan was updated in response.

7. Review of patient #5 MR lacked documentation of an updated care plan after the fall on 12/4/17 at 1805 hours or a weekly update.

8. Review of patient #6 MR indicated the following:
(A) He/she was assessed as a high risk for falls each assessment.
(B) An order was written on 11/13/17 for high fall risk precautions.
(C) His/her care plan lacked documentation that patient was a fall risk nor any fall risk precautions to be implemented.

9. Review of patient #8 MR indicated that he/she was assessed as high risk for falls with each assessment. His/her care plan included falls on the problem list, however the interventions were for low risk for falls. The section for high risk fall interventions was left blank.

10. Review of patient #10 MR indicated fall treatment plan was implemented on admission and updated weekly, but not updated after the fall on 11/19/17 at 0700 hours.

11. Staff member #A5 (Regional Clinical Director) verified the MR information for patients 3, 6, and 8 at 2:30 p.m. on 12/6/17.

12. Staff member #A2 (Administrator) verified the MR information for patients 2, 4, 5, and 10 at 2:10 p.m. on 12/6/17.


29550

Based on document review and interview, the facility failed to ensure staff assigned to patient care had specialized training and/or orientation for 5 of 5 personnel files reviewed (N1, N2, N3, N4 & N5) and failed to ensure staff were educated on current fall risk policy for all current staff members.

Findings include;

1. Facility policy titled "STAFF ORIENTATION AND TRAINING FOR RESTRAINT AND SECLUSION" last reviewed/revised 2/17 states on page 1: "During hospital orientation, the initial restraint and seclusion competency is completed, prior to participating in restraint use and then revisited."

2. Facility policy titled "STAFF COMPETENCIES" last reviewed/revised 8/2016 states on page 2: "5. Initial skills check lists and/or competencies are completed by the employees during orientation as assigned, and are reviewed by the appropriate Director and/or Supervisor."

3. Review of staff member #N1 (Licensed Practical Nurse with date of hire of 4/12/15) personnel file lacked documentation of job specific orientation and lacked evidence of training on patient rights.

4. Review of staff member #N2 (Registered Nurse with date of hire of 10/13/15) personnel file lacked documentation of job specific orientation and lacked evidence of training on patient rights.

5. Review of staff member #N3 (Registered Nurse with hire date of 9/11/17) personnel file lacked documentation of job specific orientation and lacked evidence of training on patient rights.

6. Review of staff member #N4 (Certified Nursing Assistant with hire date of 10/16/17) personnel file lacked documentation of training on patient rights.

7. Review of staff member #N5 (Certified Nursing Assistant with hire date of 10/16/17) personnel file lacked documentation of training on patient rights and restraints and seclusion.

8. Staff member #A8 (Corporate Administrator) verified the above in interview beginning at 1:30 p.m. on 12/6/17 and indicated that patient rights was covered in general orientation.

9. Review of the general orientation binder indicated that there was one (1) slide in the orientation documents that listed three (3) patient rights.

10. Review of document titled "PATIENT RIGHTS AND RESPONSIBILITIES" obtained at the front desk indicated there were > thirty (30) rights listed.

11. Review of education documents dated 11/30/17 through 12/5/17 related to plan of correction for Immediate Threat to Life determination by accrediting organization survey indicated that staff member were educated on policy titled "FALL PREVENTION PROTOCOL" with review date of 9/2017.

12. Staff member #A1 (President of Governing Board) and A8 (Corporate Administrator) indicated in interview at 4:00 p.m. on 12/6/17 that a new policy was developed as a response/plan of correction to the recent accreditation survey.

13. Staff members #A2 (Administrator), A3 (Director of Nursing), and A5 (Regional Clinical Director) indicated in interview at 4:00 p.m. on 12/6/17 that they had provided the training to staff and they did not receive a revised copy of the policy.



29550