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Based on the hospital Nursing Fall Risk and Prevention Competency review, hospital Fall Prevention Program 2020 PowerPoint review, medical record reviews, patient and staff interviews the nursing staff failed to complete hourly nurse rounding on 6 of 6 patients with a history of falls. (Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, and Patient #10)

Review on 08/12/2021 of nursing Fall Risk Prevention Competency, (no review date) revealed "...Patient Rounding. Nurses round every even hour, RNT's (rehabilitation nurse technicians) every odd hour. Nursing should round on patients to assess for the following 4 P's: Pain, Potty, Positioning needs, and Personal belongings... Just remember... It is easier to anticipate a patient's needs before they ask, than deal with a fall injury later! Help reduce fall/injury and call bell times.!"

Review on 08/12/2021 of the hospital Fall Prevention Program 2020 PowerPoint dated 03/25/2021 revealed nursing staff are responsible for a "...Fall Prevention Commitment...Ongoing: Hourly rounding with purpose-fluids, toileting, items within reach..."

1. Open medical record review on 08/11/2021 revealed Patient #5, a 78-year-old male patient admitted on 08/06/2021 for community acquired pneumonia. Admission Orders revealed a medical consult for "weakness and fatigue" was ordered by MD #1. Record review revealed that Patient #5 had an unwitnessed fall on 08/09/2021 at 0359 while ambulating in his room. Review of the Post Fall Assessment for Patient #5 dated 08/09/2021 at 0406 by Registered Nurse (RN) #3 revealed that there was no injury and she "...Re-educated patient on the importance of using the call light when wanting to be out of bed...Morse Fall Risk: Falls with injury or 2 or more falls in the past year: Yes..." Record review of the nurse Rounding documentation revealed no hourly nurse rounding on 08/10/2021 from 0156 until 0523, (3 hours and 27 minutes). Record review revealed no hourly nurse rounding on Patient #5 within 24 hours after a fall.

Request on 08/11/2021 to interview Patient #5 revealed he was unavailable for interview.

Interview request on 08/11/2021 at 0900 with RN #3 revealed she was unavailable for interview.

Interview on 08/11/2021 at 0915 with RNT #15 revealed for fall prevention, we do the rounding, make sure the patient's possessions are within reach, and the call bell is in reach ..." Interview revealed the expectation was hourly nurse rounding by the RNT's and RN's.

Interview on 08/12/2021 at 1050 with the Nurse Educator, RN #14 revealed, " ...I educate the nurses on hourly rounding during the New Hire Orientation and at nursing Skills Fair, our annual review that is held in November every year. We go through a PowerPoint to review "Code Stop" (post-fall assessment), they take a Falls test. Nurse hourly rounding is an expectation daily, evens/odd hours are shared by the RN's and RNT's ..." Interview revealed the expectation was for hourly nurse rounding to be completed.

Interview on 08/12/2021 at 1505 with Interim Chief Nursing Officer since October 2018, RN #1 revealed "...The expectation for nursing rounding was nurses and nursing techs (technicians) are to do alternate hourly rounding on all patients. I do believe it will decrease patient calls (sic)..." Interview revealed that all nursing staff complete an education competency on new hire and annually that reviews the expectation with nurse rounding hourly on all patients to decrease patient falls. Interview revealed that hourly nurse rounding should be completed.

2. Open medical record review on 08/11/2021 revealed Patient #6, a 58-year-old male patient admitted 07/31/2021 for a spinal cord injury and pain management. Record review of the nurse Rounding revealed no hourly nurse rounding on 08/05/2021 from 0611 to 2335 (17 hours and 24 minutes). Record review revealed Patient #6 had a witnessed and assisted fall on 08/07/2021 at 1245 while being transferred from the wheelchair to the bed. Review of the Post Fall Assessment dated 08/07/2021 at 1537 by RN #4 revealed "...Post Fall Status: No change from baseline...Morse Fall Risk: Falls with injury or 2 or more falls in the past year: Yes..." Record review of the nurse Rounding revealed no hourly nurse rounding on 08/09/2021 from 0451 to 2215 (18 hours and 24 minutes). Record review revealed no hourly nurse rounding on Patient #6, within 48 hours before or after a fall.

Request on 08/11/2021 to interview Patient #6 revealed that he declined interview.

Interview on 08/10/2021 at 1410 with RN #4 revealed "Patient rounds are completed hourly, the RN does the even hours, and the tech. (rehabilitation nurse technicians) does the odd hours when patients are not in therapy." Interview revealed that hourly should be completed.
Interview on 08/11/2021 at 0915 with RNT #15 when asked about nurse rounding revealed "For fall prevention, we do the rounding, make sure the patient's possessions are within reach, and the call bell is in reach ..." Interview revealed the expectation was hourly nurse rounding by the RNT's and RN's should be completed.

Interview on 08/12/2021 at 1050 with the Nurse Educator, RN #14 revealed, " ...I educate the nurses on rounding during the New Hire Orientation and at Skills Fair, our annual review that is held in November every year. We go through a PowerPoint to review "Code Stop", they take a Falls test. Nurse hourly rounding is an expectation daily, evens/odd hours are shared by the RN's and RNT's ..." Interview revealed the expectation was for hourly nurse rounding to be completed.

Interview on 08/12/2021 at 1505 with Interim Chief Nursing Officer since October 2018, RN #1 revealed "...The expectation for nursing rounding was nurses and nursing techs (technician) are to do alternate hourly rounding on all patients. I do believe it will decrease patient calls (sic)..." Interview revealed that all nursing staff complete an education competency on new hire and annually that reviews the expectation with nurse rounding hourly on all patients to decrease patient falls. Interview revealed that hourly nurse rounding should be completed.

3. Open medical record review revealed Patient #7, an 81-year-old male admitted on 07/28/2021 at 1043 status post CVA (cerebral vascular accident - stroke). Patient #6 needed physical therapy, occupational therapy and speech therapy due to new CVA and right-side weakness. Record review of the nurse Rounding revealed no hourly nurse rounding on 07/29/2021 from 0132 to 0841 (7 hours and 9 minutes) and on 08/04/2021 from 1538 to 1929 (3 hours and 51 minutes). Record review revealed Patient #7 had an unwitnessed fall on 08/04/2021 at 1825. Review of the Post Fall Assessment dated 08/04/2021 at 1833 by RN #7 revealed Patient #7 had slipped and fell while in the bathroom, "patient light was on..." Morse Fall Risk: Falls with injury or 2 or more falls in the past year: Yes..." Record review of the nurse Rounding revealed no hourly nurse rounding on 08/11/2021 from 0549 to 1413 (8 hours and 24 minutes) Patient #7. Record review revealed no nurse hourly rounding during Patient # 7's fall.

Interview on 08/12/2021 at 1105 with Patient #7 revealed " ...I put my light on and waited as long as I could, I needed to stool. I went on to the bathroom. I can't use my right side, so when I tried to undo my pants, I fell ..." Interview revealed that "most of the time they check on me regular, again it depends on who is working." Interview revealed nurse rounding was not consistent.
Interview on 08/11/2021 at 0915 with RNT #15 when asked about nurse rounding revealed " ...For fall prevention, we do the rounding, make sure the patient's possessions are within reach, and the call bell is in reach ..." Interview revealed the expectation was hourly nurse rounding by the RNT's and RN's should be completed.

Interview on 08/12/2021 at 1050 with the Nurse Educator, RN #14 revealed, " ...I educate the nurses on rounding during the New Hire Orientation and at Skills Fair, our annual review that is held in November every year. We go through a PowerPoint to review "Code Stop", they take a Falls test. Nurse hourly rounding is an expectation daily, evens/odd hours are shared by the RN's and RNT's ..." Interview revealed the expectation was for hourly nurse rounding to be completed.

Interview on 08/12/2021 at 1505 with Interim Chief Nursing Officer since October 2018, RN #1 revealed "...The expectation for nursing rounding was nurses and nursing techs (technician) are to alternate hourly rounding on all patients. I do believe it will decrease patient calls (sic)..." Interview revealed that all nursing staff complete an education competency on new hire and annually that reviews the expectation with nurse rounding hourly on all patients to decrease patient falls. Interview revealed that hourly nurse rounding should be completed.

4. Closed medical record review on 08/12/2021 revealed Patient #8, an 82-year-old male admitted on 06/25/2021 at 2056 through 07/16/2021 following a brain hemorrhage (bleeding inside the brain). Record review of the nurse Rounding revealed no hourly nurse rounding on 06/26/21 at 1953 through 2337 (3 hours and 44 minutes), 6/27/2021 at 0200 through 0719 (5 hours and 19 minutes), 06/28/2021 at 1430 through 1800 (4 hours and 30 minutes), and on 06/29/2021 at 0438 through 0849 (4 hours and 11 minutes). 1. Record review revealed Patient #8 had a "witnessed but not intercepted..." fall on 06/29/2021 at 0830. Review of the Post Fall Assessment dated 06/29/2021 at 1238 by revealed patient was found on the floor in front of his wheelchair...urinal was on the sink...Morse Fall Risk: Fall with injury or 2 + falls in the past y (year): Yes. Record review of nurse Rounding revealed no hourly nurse rounding on 07/04/2021 at 0246 through 0854 (6 hours and 8 minutes). 2. Record review revealed Patient #8 had an unwitnessed fall on 07/09/2021 at 2130. Review of Post Fall Assessment dated 07/10/2021 at 1938 by RN #10 revealed "...Patient had gotten up and ambulated to the bathroom without calling staff for assistance; bed alarm was not on at the time of fall...Morse Fall Risk: Fall with injury or 2 + in the past y: Yes..." Record review of nurse Rounding revealed no hourly nurse rounding on 07/11/2021 at 2342 through 0727 (7 hours and 45 minutes). 3. Record review revealed Patient #8 had an "...witnessed but not intercepted fall..." on 07/11/2021 at 1700. Review of the Post Fall Assessment dated 07/11/2012 at 1713 by RN #11 revealed "Patient was accompanied to the bathroom, slipped while getting up from the wheelchair...Morse Fall Risk Fall with injury or 2 + falls in the past y: Yes." Record review of the nurse Rounding revealed no nurse hourly rounding on 07/15/2021 1836 through 0716 (12 hours and 40 minutes). Record review revealed no nurse hourly rounding during Patient #8's fall.

Interview on 08/11/2021 at 0915 with RNT #15 when asked about nurse rounding revealed " ...For fall prevention, we do the rounding, make sure the patient's possessions are within reach, and the call bell is in reach ..." Interview revealed the expectation was hourly nurse rounding by the RNT's and RN's should be completed.

Interview on 08/12/2021 at 1050 with the Nurse Educator, RN #14 revealed, " ...I educate the nurses on rounding during the New Hire Orientation and at Skills Fair, our annual review that is held in November every year. We go through a PowerPoint to review "Code Stop", they take a Falls test. Nurse hourly rounding is an expectation daily, evens/odd hours are shared by the RN's and RNT's ..." Interview revealed the expectation was for hourly nurse rounding to be completed.

Interview on 08/12/2021 at 1505 with Interim Chief Nursing Officer since October 2018, RN #1 revealed "...The expectation for nursing rounding was nurses and nursing techs (technician) are to alternate hourly rounding on all patients. I do believe it will decrease patient calls (sic)..." Interview revealed that all nursing staff complete an education competency on new hire and annually that reviews the expectation with nurse rounding hourly on all patients to decrease patient falls. Interview revealed that hourly nurse rounding should be documented when completed.

5. Closed medical record review on 08/11/2021 revealed Patient #9, a 77-year-old male admitted on 07/09/2021 at 1302 through 07/18/2021 after having a "Myocardial Infarction" (heart attack). Review of nurse Rounding revealed no nurse hourly rounding on 07/10/2021 from 0216 through 0800 (5 hours and 44 minutes), on 07/11/2021 at 2337 through 0730 (7 hours and 53 minutes), and on 07/13/2021 at 0324 through 0813(4 hours and 49 minutes). Review of the record revealed Patient #9 had an unwitnessed fall on 07/13/2021 at 1345. Review of the Post Fall Assessment dated 07/13/2021 at 1416 by RN #12 revealed "Patient reports he slid out of his chair...Morse Fall Risk Falls with injury or 2 or more falls in the past year: yes. Review of nurse Rounding revealed no nurse hourly rounding on 07/18/2021 at 1821 through 0123 (7 hours and 2 minutes) and on 07/18/2021 at 0200 through 0630 (4 hours and 30 minutes). Record review revealed no hourly nurse rounding on Patient #9 within 24 hours of a fall.

Interview on 08/11/2021 at 0915 with RNT #15 when asked about nurse rounding revealed " ...For fall prevention, we do the rounding, make sure the patient's possessions are within reach, and the call bell is in reach ..." Interview revealed the expectation was hourly nurse rounding by the RNT's and RN's should be completed.

Interview on 08/12/2021 at 1050 with the Nurse Educator, RN #14 revealed, " ...I educate the nurses on rounding during the New Hire Orientation and at Skills Fair, our annual review that is held in November every year. We go through a PowerPoint to review "Code Stop", they take a Falls test. Nurse hourly rounding is an expectation daily, evens/odd hours are shared by the RN's and RNT's ..." Interview revealed the expectation was for hourly nurse rounding to be completed.

Interview on 08/12/2021 at 1505 with Interim Chief Nursing Officer since October 2018, RN #1 revealed "...The expectation for nursing rounding was nurses and nursing techs (rehabilitation nurse technicians) are to alternate hourly rounding on all patients. I do believe it will decrease patient calls (sic)..." Interview revealed that all nursing staff complete an education competency on new hire and annually that reviews the expectation with nurse rounding hourly on all patients to decrease patient falls. Interview revealed that hourly nurse rounding should be completed.

6. Open medical record review on 08/10/2021 revealed Patient #10, a 73-year-old male admitted following a left hip fracture. Review of the nurse Rounding revealed no hourly nurse rounding on 07/28/2021 1756 through 2106 (3 hours and 10 minutes), and on 08/02/2021 from 0101 through 0738 (6 hours and 37 minutes). Record review revealed Patient #10 had an unwitnessed fall on 08/02/2021 at 0215. Review of the Post Fall Assessment dated 08/02/2021 at 1506 by RN #13 revealed Patient #10 did not call for assistance prior to getting up to use his urinal. Review revealed "Nurse heard patient's fall and found patient on the floor ...Morse Fall Score Falls with injury or 2 or more falls in the past year: Yes ..." Review of the nurse Rounding revealed no hourly nurse rounding on 08/07/2021 from 0929 through 1435 (5 hours and 36 minutes) and on 08/09/2021 at 1201 through 1859 (6 hours and 58 minutes). Record review revealed no nurse hourly rounding occurred during Patient #10's fall.

Interview request on 08/10/2021 at 1615 for RN #13, revealed she was unavailable for interview.
Interview on 08/11/2021 at 0915 with RNT #15 when asked about nurse rounding revealed For fall prevention, we do the rounding, make sure the patient's possessions are within reach, and the call bell is in reach ..." Interview revealed the expectation was hourly nurse rounding by the RNT's and RN's should be completed.

Interview on 08/12/2021 at 1050 with the Nurse Educator, RN #14 revealed, " ...I educate the nurses on rounding during the New Hire Orientation and at Skills Fair, our annual review that is held in November every year. We go through a PowerPoint to review "Code Stop", they take a Falls test. Nurse hourly rounding is an expectation daily, evens/odd hours are shared by the RN's and RNT's ..." Interview revealed the expectation was for hourly nurse rounding to be completed.

Interview on 08/12/2021 at 1505 with Interim Chief Nursing Officer since October 2018, RN #1 revealed "...The expectation for nursing rounding was nurses and nursing techs (technician) are to alternate hourly rounding on all patients. I do believe it will decrease patient calls (sic)..." Interview revealed that all nursing staff complete an education competency on new hire and annually that reviews the expectation with nurse rounding hourly on all patients to decrease patient falls. Interview revealed that hourly nurse rounding should be completed.