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A. Based on record review, document review and interview it was determined the facility failed to ensure nursing adhered to policies and procedures of the hospital by failing to notify the family of a patient's fall in (1) out of five (5) patients, patient #1, who experienced a fall while receiving care at the facility. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

1. Patient #1's medical record was reviewed on 06/01/21. The patient was transferred to the facility from an acute hospital facility for rehabilitation following a hospital stay for respiratory and metabolic encephalopathy on 03/06/21. On 03/19/21 the patient experienced a fall during her physical therapy discharge evaluation. Registered Nurse (RN) #1 documented on the 'Post Fall Assessment' "...Patient Approved Family Notification: Yes ...Patient's bedside nurse, Licensed Practical Nurse (LPN) #1, will notify family of fall." No further documentation was noted about notification of the family after the patient fall. Patient #1's discharge was put on hold for further evaluation of injuries.

2. A policy titled 'Fall Prevention Program,' last review date 03/04/21, was reviewed on 06/01/21. The policy states in part: "Policy: X. Post Fall Procedures/Management... 2. Documentation/Follow Up: The following documentation should be completed on each fall: A. Notify family/support."

3. An interview was conducted with RN #1 on 06/01/21 at 1:08 p.m. She remembered the fall involving patient #1. She stated, "I read through her chart and did the post fall assessment since her bedside nurse was a LPN that day and she cannot do the post fall assessment. I did not notify the family myself. I answered yes to the family being notified since you had to put either yes or no and put a note the bedside nurse (LPN #1) was to notify the family. I was both Charge Nurse and Supervisor that day, so I never went back to check with (LPN #1) to see if she called the family."

4. An interview was conducted with LPN #1 on 06/01/21 at 1:39 p.m. She remembered patient #1 but did not remember the events of the day of her fall or if she notified the patient's family of the fall.

5. An interview was conducted with the Program Director on 06/01/21 at 10:30 a.m. She confirmed that patient #1's daughter filed a complaint on 03/20/21 after finding out from patient #1 herself on the morning of 03/20/21 that she had fallen the previous day.

B. Based on record review, document review and interview it was determined the facility failed to ensure nursing adhered to policies and procedures of the hospital by failing to document a post fall assessment, including notifying the physician, in (1) out of five (5) patients, patient #11, who experienced a fall while receiving care at the facility. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

1. Patient #11's medical record was reviewed on 06/02/21. The patient was transferred to the facility from an acute hospital facility for rehabilitation following a hospital stay for pacemaker placement and acute kidney injury on 05/10/21. RN #2's documentation states on 05/19/21 at 10:12 a.m., "Patient's family was called to report fall that occurred around 0630 on 05/19/21. There was no answer for the call and there was no voicemail available. Will continue to monitor patient." On 05/19/21 at 10:20 a.m. it is documented by RN #2, "Patient's family member returned call regarding the fall that occurred today. Family member was notified that the alarms were going off during the time of the fall and that no injuries occurred with the patient. There are no concerns at this time." There is no further documentation of a fall, no 'Post Fall Assessment' form and no mention of the fall in the 'Physician Progress Notes.'

2. A policy titled 'Fall Prevention Program,' last review date 03/04/21, was reviewed on 06/01/21. The policy states in part: "Policy: X. Post Fall Procedures/Management 1. Initial Post Fall Assessment/Follow-up: A. A post fall assessment will be performed by a licensed RN/PT/OT/SLP appropriate to their clinical scope of practice and any obvious injuries or change in status must be thoroughly assessed .... B. Vital Signs C. Notify Physician ...2. Documentation/Follow Up: The following documentation should be completed on each fall: ...B. The Post Fall Assessment documentation should be completed describing the fall and including the results assessment."

3. An interview was conducted with the Chief Nursing Officer on 06/02/21 at 1:01 p.m. She confirmed there was no further documentation of a 'Post Fall Assessment' for patient #11 or documentation the physician was notified of the fall.