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Based on record review and interview the facility failed to ensure wheelchair seatbelt was used per fall prevention policy and procedure. Failure to follow fall prevention policy created a potential for patient harm. Citing 1 of 1 patient medical records reviewed. (Patient #1).

Review of patient #1 medical record on 4/9/2013 at 11:00 am revealed the following:

Review of nurses notes dated 12/22/2012 at 10:42 am revealed the following:
Assessment Focus Note:
Identified problems from team documentation:
Problem: Impaired Cognition:
Problem: Impaired Endocrine/Metabolic Function
Problem: Impaired Mobility
Problem: Impaired Pain Management
Problem: Impaired Psychosocial Skills/Behavior
Problem: Impaired Self-care Mgmt/ADL/IADL.
Problem: Risk of Infection
Problem: Safety Risk

Review of nurses notes dated 12/23/2012 at 11:450 pm revealed the following:
Assessment Focus Note: At 3:45 am patient returning from bathroom-accompanied by Patient Care Assistant; patient stood up without waiting for assistance, tripped and fell sideways, hitting head-landed face down on floor (did not injure face); Assisted to bed-denies pain anywhere and is moving all extremities. See Neuro check. Superficial scrape to left knee (no bleeding). Goose egg to left forehead noted-ice pack applied. Patient Physician informed at 3:50 am. At 6:30 am condition stable-neuro checks and vital signs stable. At 7:50 am spoke with patients daughter regarding patient fall. All questions answered and advised notification of physician. Order to send patient for Cat Scan to be sure no skull fracture. Daughter anxious and upset and requesting to speak with supervisor. Agreed to speak with weekend supervising Charge Nurse regarding questions concerning her mothers care. Phone number given to Charge Nurse. Patient currently sitting in dining room to eat. No change in condition.

Review of nurses notes dated 12/24/2012 at 1:30 pm revealed the following:
Risk for falls status: patient fell on 12/23/2012. Family request patient be gotten up on patient's right side of bed where there is more room to maneuver. Focus note at 5:30 pm: Condition is stable and unchanged. Slept well and denies pain this shift.

Review of Physician Rehab Progress Note dated 12/23/2012 at 4:45 am revealed the following:
Physical Exam: Alert. She had a fall last night, was impulsive, according to RN. She was with aid, and got up before aid could come around to help her, has soft tissue injury to forehead, no loss of consciousness and neuro signs stable. No change is B/P and heart rate is good.
Plan: She was doing OK, but refused some therapy yesterday, then this AM got up from wheel chair impulsively before aid could come around to help her, and fell hit her forehead on the wall, has soft tissues swelling. Neuro-vascular signs are unchanged. Will get Cat scan of head to r/o skull fracture. Otherwise she is doing OK but impulsive, will monitor closely and continue with her program as tolerated.

Review of Physician Rehab Progress Note dated 12/25/2012 at 5:31 am revealed:
Physical Exam: Alert. She is doing OK. Cat scan of head show Microvascular dis and atrophy, no fracture or acute changes, just scalp hematoma. Blood Pressures are stable, blood sugars are up in the evening, will split dose Lantus for now.

Review of ETMC Rehabilitation Hospital Policy #3170 Effective April 1995 Last Revision: April 2012
Subject: Fall Precaution Program revealed the following:
Policy: ETMC Rehabilitation team members shall provide a safe, secure environment for patients with impaired cognition, sensory deficits, impaired mobility, etc. Patients will be assessed for risk of falls on admission, as part of the nursing shift assessment, and at least weekly with team conference. More frequent reassessment will be done by the treatment team according to patient need, behavior, and condition. Safety levels will be assessed according to criteria below and professional judgment. Patient's safety needs are addressed in the Interdisciplinary Treatment Plan.
Procedure: Assessment
1. The patient is identified as requiring safety interventions by the admitting Registered Nurse. Safety interventions are categorized as Safety Levels 1-5.
2. The following criteria and point system are used to guide the Registered Nurse in this identification.
Point Criteria:
10 This hospitalization caused by a fall
25 History of multiple falls previous to this hospitalization
25 Impulsiveness
25 Unilateral neglect
20 Impaired cognition, confusion, disorientation, impaired memory or judgment, inability to understand and follow directions.
25 Postural hypotension
10 Altered proprioception
5 Altered bladder functions
5 Impaired mobility, use of ambulating device
5 Special medication categories with routine use (narcotics, sedatives, psychotropic's, hypnotics, tranquilizers, antidepressants)
5 Lowered ability to perform ADL's
5 Altered sleep patterns
5 Presence of psychiatric diagnosis
3. The admitting Registered Nurse will identify all new admissions as Level 2 unless the points total 30 more. Patients with fall risk scores of 30 points or more will be identified at Safety Level 3. Patients will be identified as Level 4 if Level 3 is ineffective. Level 4 will be initiated on admission if there was constant supervision required at the previous care setting immediately prior to transfer to the rehabilitation setting. Level 5 (restraint) is only used when all other alternatives are ineffective.
4. Therapy staff will review the Safety Level and confer with the responsible Registered Nurse upon completion of initial evaluations to collaborate on the appropriateness of the Safety Level and determine seating or positioning adaptions as needed.
5. Definitions:
A. Safety Level 1 indicates that the patient is independent in monitoring his own safety precautions. He has demonstrated no unsafe behaviors and calls for assistance appropriately. Level 1 will not be assigned to a new admit to allow ample time for a full assessment of safety needs. A patient's transfer status does not affect the Safety Level.
B. Safety Level 2 indicates that the patient has scored less than 30 points on admission and further time may be needed to determine a more appropriate level, or that if assigned a Level 3 on admit, has since demonstrated enough safe behavior, as determined by the team, to be assigned Level 2.
C. Safety Level 3 indicates that the patient scored more than 30 points on admission and is high risk for falls. Patients previously assessed to be at Level 4 or 5 may be reduced to Level 3 if the treatment team assesses improvement in safe behaviors.
D. Safety Level 4 indicates that Level 3 has not been effective in addressing a patient's unsafe behavior and constant supervision/hands off is required.
E. Safety Level 5 indicates that the patient has demonstrated behavior that meets criteria for restraint.
Interventions:
1. Rehabilitation Team members will use the Interdisciplinary Treatment Plan and the "dry erase board" in the patient's room to indicate the current Safety Level, safety interventions and transfer techniques.
2. Interventions by Level:
Safety Levels Interventions
Level 1 - Provide daily patient/family education on fall prevention and interventions, including the use of wheelchair seatbelts, appropriate footwear and call light within reach at all times.
Level 2 - 1 plus side rails times 2 or 3, bed alarm, wheelchair seatbelt, use of gait belt for patients who require assistance with transfers or ambulation, non-skid foot wear, and frequent safety education. Hand held call lights deactivate the bed alarms. Patients will need bed check added as a substitute for the bed alarm with special beds.
Level 3 - Level 2 plus frequent checks every hour and LAMP; bed check and/or chair check; implement additional fall precaution safeguards as indicated. (See #4 below)
Level 4 - Level 2 and 3 plus hand-off, video, or 1:1 companion- Communicate patient specific plan or patient white board, treatment plans, and at hand-off.
Level 5 - Levels 2, 3, and 4 plus implementation of restraints/direct observation.
3. The patient identified at Level 3-5 will:
A. Wear a yellow wrist band which will be applied by the responsible Registered Nurse. Using a permanent marker, the nurse will document "falls" on the wrist band as one means of communicating the patient's status to all team members.
B. Have the LAMP protocol initiated. LAMP is an acronym for Look At Me Please. Patient's determined to meet criteria for Level 3 or above will have the LAMP program implemented as follows:
1. The patient's name will be highlighted in yellow at the room door sign.
2. A magnetic 'lamp' sign will be placed on the door frame next to the patient's name.
3. Any staff member passing the room will check on patient's identified with LAMP program indicator and assess the need for safety intervention.
4. The above safeguards will be initiated by the admitting Registered Nurse. All subsequent team members will continue to maintain all indicated interventions. Additional fall precautions may include the following; depending on patient needs:
A. Protective devices utilized as needed, i.e., lapboard, torso vest (Velcroed in the front), lap hugger, wedge wheelchair cushions, etc. that are used as safety reminders or posture/positioning devices but do not restrict the patient's freedom.
B. Removal of wheelchair at bedside.
C. Placement of patient on commode chair at bedside or in bathroom rather than directly on toilet.
D. Establish routine toilet schedule. Do not leave patient alone in the bathroom.
E. High-low bed.
F. Mattress on floor.
G. Request that family stay or provide someone to stay with patient.
5. When non-restrictive safety measures are insufficient to provide adequate safety for the patient, use of direct observation and/or use of restraints may need to be considered. Use of restraints requires the order of a physician, and may only be used when other safety alternatives have not been successful.
6. Between team conferences a Registered Nurse may determine that a patient's behavior necessitates a change to a more intense safety level and implement the interventions necessary for the patient's safety. Moving a patient to a less intense safety level should include collaboration with members of the interdisciplinary team.
7. At any time, any team member can identify a patient they feel meets criteria for a higher or lower Safety Level assessment, and initiate discussion with the interdisciplinary team.
Documentation:
1. The Registered Nurse documents the admission assessment of the patient's safety in the Nursing Admission Assessment using the points criteria as a guideline.
2. Rehabilitation Therapists document the patient's limitations to safe behavior with their initial evaluations.
3. Ongoing documentation:
A. The patient's safety level is documented by the nurse in the daily shift assessment, and as needed, based on patient's safety behavior.
B. Patient's safety awareness, behaviors, etc. are documented in the daily notes by therapists and nurses.
C. Changes in interventions and patient's responses are documented in the daily notes by the rehabilitation team members including associated changes to the treatment plan.
D. Discussion of fall prevention needs and plans is documented in the team conference as part of the interdisciplinary treatment plan.
E. Ongoing patient/family safety education/reinforcement is documented in the patient record.

Interview with staff #2 on 4/10/2013 at 5:00 pm per telephone revealed the following:
"I heard staff #3 call out for help on the night of 12/23/2012 at 3:34 am and I went in to help. Staff #3 said she had just taken patient to the bathroom and had pushed wheelchair up to side of the bed and was locking the wheels, when the patient starting getting up before she could get around to help her. The complainant thought staff #3 should've been in front of her patient instead of behind her. Staff #3 was just locking the wheelchair and was headed to help patient back into bed. As far as I know staff #3 did everything she could to prevent the fall. The goal of rehab is patient independence, and sometimes they think they can do more than they actually can. The patient may have also been a little sleepy and just forgot to wait for help. I can't remember if staff #3 used the seatbelt on the wheelchair. We both tried to assist the patient back to bed and called physician and did neuro checks and vital signs to monitor patient."

Interview with staff #3 on 4/10/2013 at 5:30 pm per telephone revealed the following:
"I went in to help patient to the bathroom and we were on our way back to the bed. I was pushing the patient and as I locked the wheelchair the patient all of the sudden started getting up and started falling. I called for help and then went to check on patient. The patient still required a lot of help getting up out of the wheelchair, and she may have been a little sleepy and just forgot to wait on me to help her. She is such a nice lady and I hated she fell. I ask her what happened and she told me she didn't know and just laughed and said she was fine and not hurt. Her daughter then didn't want us to get her up on the right side of the bed, so we wrote it on dry board and updated her care plan and started using the left side of the bed for getting up and out of the bed. It did provide more room to assist the patient. We called the doctor and did vital signs and neuro check as ordered. She was just one of the sweetest patients and I hated so much she fell. I don't remember if the wheelchair had a seatbelt or not."

Interview with staff #1 on 4/9/2013 at 12:30 pm confirmed the findings.

Based on record review and interview the facility failed to ensure the registered nurse evaluated patient care. The registerd nurse also failed to ensure patient care was carried out per physican orders. Citing 1 of 1 patient record reviewed. (Patient #1)
Medical record review for patient #1 on 4/9/2013 at 11:00 am revealed the following:
Physician order dated 12/19/2012 revealed the following:
1. TED hose-Knee High; on during the day and off at night.
2. Turn side-back-side every 3-4 hours.
Review of nurses notes and 24 hour patient care assessment record for the dates 12/19/2012 thru 1/4/2013 provided no documentation that TED hose were every used for patient care.
Review of 24 Hour Patient Care Assessment revealed the following:
12/20/2012: No documentation of patient position found between 7:30 am thru 9:30 am. At 10:00 am and 1:00 pm patient documented on side. At 4:16 pm, 7:13 pm, 8:10 pm, 9:32 pm, 10:19 pm patient documented on back.
12/21/2012: at 12:00 am, 2:30 am, and 4:12 am patient documented on back. No documentation found after 4:12 am until 7:55 pm. At 7:55 pm, 8:55 pm, 9:30 pm, and 10:20 am patient documented on his back.
12/22/2012: 12:25 am, 1:45 am, 3:00 am, 3:50 am, 4:10 am, 6:00 am, and 7:10 am patient documented on back. From 7:10 am until 2:10 pm no documentation of patient position. At 2:10 pm, 3:27 pm, 7:18 pm, 8:13 pm, 9:45 pm, 10:17 pm and 11:40 pm patient position documented on back.
12/23/2012: At 1:30 am patient documented on right side. At 3:45 am, 4:30 am, and 5:30 am patient documented on back. At 6:20 am patient documented on right side. From 7:05 am thru 3:25 pm patient documented on back. At 7:16 pm, 8:05 pm, 9:00 pm, 9:16 pm, 10:26 pm, and 11:50 pm patient position documented on back.
12/24/2012:1:50 am, 3:30 am, 6:15 am, 7:20 am thru 2:15 pm, 3:28 pm, 6:32 pm, 7:03 pm, 9:45 pm, 10:00 pm, and 11:25 pm patient position documented on back.
12/25/2012: 12:25 am, 1:00 am, 1:45 am, 2:10 am, 3:40 am, 5:20 am, 7:10 am, 10:10 am, 2:20 pm, 4:15 pm, 8:17 pm, 10:10 pm, and 11:35 pm patient position documented on back.
12/26/2012: 1:30 am, 2:30 am, 4:20 am, 6:00 am patient position documented on back. At 9:00 am, 10:00 am, 10:25 am, 10:55 am, 11:05 am documentation of patient position illegible. At 3:35 pm, 6:20 pm, 8:30 pm, and 11:40 PM patient position documented on back.
12/27/2012: 1:10 am, 2:30 am, 3:02 am, 5:18 am, 6:00 am patient position documented on back. From 6:00 am until 6:45 pm patient position documented on back. From 6:45 pm until 12:00 midnight patient position documented on back.
12/28/2012: 6:10 am patient position documented on back. At 9:00 am patient position illegible. At 1:00 pm patient position documentation illegible. At 7:40 pm, 9:00 pm, 9:30 pm, 10:20 pm, and 11:25 pm patient position documented on back.
12/29/2012: At 1:30 am, 3:35 am, and 5:45 am patient position documented on back. At 9:30 am and 10:00 am patient position illegible. At 1:46 pm, 6:30 pm, 8:30 pm, 9:05 pm, and 10:30 pm patient position documented on back.
12/30/2012: At 12:00 midnight, 1:00 am, 3:45 am patient position documented on back. At 5:12 am patient position documented on right side. At 1:00 pm patient position documented on right side. At 7:30 pm, 11:00 pm, and 11:30 pm patient position documented on back.
12/31/2012: At 1:00 am, 2:15 am, 3:00 am, 3:40 am, 4:00 am, and 5:00 am thru 9:15 pm patient position documented on back.
1/1/2013: At 12:00 midnight, 1:35 am, 2:50 am, 4:10 am, and 5:45 am patient position documented on back. At 9:00 am and 10:00 am documentation of patient position illegible. At 8:00 pm, 10:00 pm, and 11:50 pm patient position documented on back.
1/2/2013: 12:10 am, 1:40 am, and 3:40 am patient position documented on back. At 4:45 am patient position documented on right side. At 9:00 am, 10:55 am, and 1:30 pm documentation of patient position illegible.
1/3/2013: 12:10 am and 1:10 am patient position documented on back. At 2:50 am patient position documented on right side. At 3:20 am and 5:49 am patient position documented on back. At 10:00 am documentation of patient position illegible. At 7:30 pm and 9:05 pm patient position documented on back. 1/4/2013: 12:05 am, 1:30 am, 3:30 am, and 5:45 am patient position documented on back.
Interview with staff #1 on 4/9/2013 at 12:30 pm confirmed the findings.