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Based on observation and staff interview, the facility failed to ensure hazardous area one hour fire rated construction was maintained (K321). The facility failed to ensure smoke detectors were not located near air flow devices (K341). The facility failed to ensure fire alarm initiating devices were located within proper distance of exit discharge (K342). The facility failed to ensure there were no penetrations in the smoke barriers (K372). The facility failed to ensure smoke barrier doors were properly maintained. (K374). The facility failed to ensure electrical outlets were properly maintained (K912). The facility failed to ensure extension cords were properly utilized (K920). The facility failed to ensure rooms containing medical gas storage had the proper signage (K923).

Based on record review, staff interview and policy and procedure review, the facility failed to ensure post fall assessments were completed for two of 13 patient records reviewed with falls (Patient #8 and #14). The census was 48.

Findings include:

Review of the policy and procedure titled Fall and Injury Prevention, policy number RH-CL-114, origination date: 12/08/09; revised date: 01/01/19, review date: 01/01/19 revealed patients who sustained a fall will be assessed for any signs of injury and treated accordingly. Ongoing assessments as appropriate, should be documented in the electronic medical record. A post fall huddle using the Post Fall Event Form will occur following the fall, as soon as the patient has been treated and stabilized. A comprehensive nursing note should be entered in the medical record to include a description of the event, results of a head to toe assessment, patient condition, interventions, names of physician and family member notified, and patient outcome. If the fall occurs in therapy, the therapist will also document a comprehensive note regarding the event. Any changes to the care plan and/or additional patient education should be documented post fall.

1. Review of Patient #8's medical record revealed the patient was admitted to the hospital on 12/11/18. The patient was identified as a high risk for falls due to behavioral issues. The patient had a non traumatic brain injury with intoxication delirium, alcohol cirrhosis, hepatic encephalopathy, shuffling gait, and bipolar disorder. Nursing notes dated 12/14/18 at 8:30 AM revealed the patient was sitting in his/her wheelchair and slid onto floor. The patient was not injured. The physician was notified. There was no evidence of a post fall assessment.

Interview with Staff C on 03/28/19 at 1:09 PM revealed no post fall assessment could be located.

2. Review of Patient #14's medical record revealed the patient was admitted on 02/12/19 with diagnoses that included a right below the knee amputation. The patient was identified as a low fall risk. The patient fell in the shower room on 02/26/19. There was no evidence of a post fall assessment.

Interview with Staff C on 03/28/19 at 2:34 PM revealed no post fall assessment could be located.

Based on observation and staff interview, the facility failed to meet the provisions of the Life Safety Code of the National Fire Protection Association (NFPA) 101, 2012 Edition, Chapter 19 Existing Health Care Occupancies. This had the potential to affect all patients receiving services from this facility. The census was 48.

Findings include:

K321 - Hazardous area one hour fire rated construction not maintained
K341 - Smoke detectors were located near air flow devices
K342 - Fire alarm initiating device was not located within proper distance of exit discharge
K372 - Penetrations in the smoke barriers
K374 - Smoke barrier doors were not properly maintained
K912 - Electrical outlets not properly maintained
K920 - Extension cords were not properly utilized
K923 - Rooms containing medical gas storage did not have the proper signage.