HospitalInspections.org

Based on document review and interview, facility nursing staff failed to notify a provider immediately after a patient fall with injury, failed to notify a family member of a patient fall with injury, and failed to complete post fall neurological checks after an unwitnessed fall for 1 of 10 medical records reviewed. (P1)


Findings Include:

1. Facility policy titled," FALL-RISK ASSESSMENT AND PREVENTION", policy number NR.02, last revised 11/2024, indicated under PROCEDURE: Nursing Responsibility Post Fall: In the event of a patient fall moving the patient the Registered Nurse will: 3. Complete neuro-checks for every unwitnessed fall; witnessed falls where patients hits their head; or as ordered by the provider. 5. Notify the provider immediately and determine if a patient requires a higher level of care.

2. Facility policy titled," INCIDENT REPORTS", policy number NU.28, last revised 7/2018, indicated under PROCEDURE: TAKING ACTION AND COMPLETING THE INCIDENT REPORT: The completed incident report reflects documentation that the following actions have occurred: Family/significant other of the patient notified of incident/injury after physician is notified.

3. Review of P1's MR (Medical Record) indicated P1 suffered an unwitnessed fall at approximately 1:18 am on 11/2/25. P1 was discovered in his/her room on the floor. P1 was noted to have a small abrasion above the right eye. P1's range of motion was intact post fall. No other injuries were noted. Documentation did not specify which parties were notified. Post fall documentation lacked neurological check data post fall.

4. Incident report documentation for P1 indicated on 11/2/25 at approximately 1:20 am P1 had an unwitnessed fall and was found on the side of the bed during rounding. P1 sustained an abrasion above the right eye and hematoma. Incident report for P1 lacked documentation of family notification of P1's fall with injury.

5. In interview on 12/17/25 at approximately 11:12 am with N3 (Licensed Practical Nurse) confirmed when a patient has a unwitnessed fall the provider, chief executive officer, director of nursing, and family of the patient are to be notified immediately as protocol indicates, neurological checks are to be documented either in the electronic medical record or in paper form which is then scanned into the electronic medical record. If a patient's fall is unwitnessed neurological checks are mandatory.

6. In interview on 12/16/25 at approximately 4:20 pm A2 (Chief Executive Officer) nursing staff did not notify a provider immediately after P1's fall with injury, N1 (Licensed Practical Nurse) did not notify P1's family of his/her fall with injury, nursing staff did not initiate, conduct, and/or document completed post fall neurological checks, but should have.