HospitalInspections.org

Based on document review and interview, the facility failed to ensure patients receive care in a safe setting by failure to take action after numerous falls for 10 of 11 MRs (Medical Records) reviewed. (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10)

The cumulative effect of this systemic problem resulted in the hospitals inability to promote Patient Rights in a safe setting.

Based on document review and interview, the facility failed to ensure patients receive care in a safe setting by failure to take action after numerous falls for 10 of 11 MRs (Medical Records) reviewed. (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10)

Findings include:

1. Facility policy titled Rights and Responsibilities of the Individual, Policy No.: RE 09, Reviews: 12/2023, Page 1, under Procedure: You have the right to: Page 2, 4. Be treated in a safe environment.

2. Facility policy titled Nursing Assessment of Patients, Policy No.: NU 09, Revised 6/2025, Page 1, under Policy: All patients admitted to this Hospital will be placed on fall prevention protocol. Interventions: Low Risk Fall Interventions: a) Orient to new surroundings including call light. b) Yellow wrist band on patient. c) Bed alarms on when patient in bed and always on high sensitivity. e) Employee is to remain with patient while toileting. f) Call light in reach. k) Every 15-minute safety checks by MHT's (Mental Health Technicians), CNA's (Certified Nursing Assistants). p) Falls NANDA (the nursing diagnosis Risk for Falls care plan) for every patient. High Risk Fall Interventions/Identifiers: All low risk interventions plus one or more of the following: b) All patients in wheelchairs must have a chair alarm. e) Safe sitter/1:1. Staff member will be within 3 feet/arm's length reach of patient at all times. Staff member will be only responsible for the 1:1 assignment to prevent distraction. Patient will also be accompanied by staff members when going to the bathroom, even if independent level of function. Physician order required and requires physician assessment and renewal every 24 hours. Page 2, f) Placement within line of sight/LOS. Staff member must be able to maintain an unobstructed view of the patient and be able to reach the patient easily and safely to ensure proper safety of patient. Post Fall Investigation: 4. Upon review, environmental and human factors that are deemed of modification, education, counseling etc. will be implemented.

3. Review of P1 MR (Medical Record) indicated:
a. On 6/7/25 at 1825 hours a fall impact was heard and the patient was found lying on the ground on his/her back with other staff present by his/her side. Patient hit his/her head on the ground, had a knot on the back of his/her head, and a small laceration with a scant amount of blood. Patient did not lose consciousness but complained of dizziness immediately after the fall. Patient transported to ED by EMS. Inc MR lacked documentation of falls risk care plan with goals and interventions in place and/or to update to prevent further falls. The patient was on Eliquis (a blood thinner which can cause bleeding).
b. On 6/11/25 at 2017 hours P1 was in the dayroom confused and climbing out of a chair, unable to redirect, staff attempted to help P1 lay down, bed alarm sounded, and staff found P1 had fallen unwitnessed around 2017 hours. P1 reported she hit her head, head pain, and had a small skin tear on right elbow. P1 transported to ED by EMS (Emergency Medical Services at 2055. MR lacked documentation of falls risk care plan with goals and interventions in place and/or to update to prevent further falls.
c. On 6/14/25 at 0705 hours P1 was standing at the end of a table with both hands on the table. Patient's legs began to bend, and she fell to the floor landing on his/her right side. Patient's head was not hit and he/she was assisted to chair with no injuries noted. MR lacked documentation of falls risk care plan with goals and interventions in place and/or to update to prevent further falls.
d. On 6/14/25 at 0958 hours P1 was ambulating in common area, began to stumble backwards, fell and hit his/her head. No apparent injury noted to head, right elbow bleeding from an old intact scab, patient denied pain and lower extremities were equal in length. MR lacked documentation of falls risk care plan with goals and interventions in place and/or to update to prevent further falls.
e. On 6/15/25 at 0043 hours P1 arrived back from the ED at 0015 hours, vital signs stable, patient drowsy, confused, and appeared he/she would sleep. P1 transferred to bed with 3 bedrails up and bed alarm set. The bed alarm sounded at 0043 hours, technician went into patient's room, and found the patient lying on his/her right side on the floor a few steps away from the bed. Patient transported to the ED. MR lacked documentation of falls risk care plan with goals and interventions in place and/or to update to prevent further falls.
f. On 6/15/25 at 1245 an order had been received at 1224 hours for P1 to be 1:1 observation and reassessed at the end of every shift. At 1245 P1 got up from the chair, was unsteady, began walking, leaning his/her body to the right, stumbled into the wall and fell to the floor landing on his/her right side. P1 had a red bump to the back of his/her head and complained of soreness to all of his/her body. 911 called and patient transported to ED at 1307 hours. MR lacked documentation of falls risk care plan with goals and interventions in place and/or to update to prevent further falls.
g. On 6/16/25 at 1630 hours the patient received a laceration to his/her upper brow. According to the 1:1 staff member, the patient had a bowel movement, staff took patient into bathroom to clean him/her up, patient began moving around on the toilet while staff was cleaning him/her up, leaned to the right causing him/her to hit his/her head on the handrail in the bathroom causing a two inch laceration to his/her right brow. EMS phoned and transported the patient to the ED at 1904 hours. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.

4. Review of P2 MR indicated:
a. On 2/19/25 at 1829 hours, one hour after arriving at the facility, the patient was standing at the nurse's station and fell on his/her buttocks. MR lacked documentation of falls risk care plan with goals and interventions in place and/or to update to prevent further falls.
b. On 2/22/25 at 1930 hours the patient was a high-risk fall with every 15-minute checks in place. The patient was in a wheelchair, the patient got up out of the wheelchair, walked to nurse's station desk, lost his/her balance and fell to the floor hitting his/her right elbow. The patient did not hit his/her head. Bruising and skin tears were noted to the right elbow. The patient did not have a wheelchair alarm in place. MR lacked documentation of falls risk care plan with goals and interventions in place and/or to update to prevent further falls.
c. On 2/25/25 at 2208 hours the patient had a fall in the milieu. Patient was at the nurse's station standing, turned to walk back to the other end of the milieu, was not near his/her wheelchair, took a couple of steps, lost his/her balance, initially recovered and stabilized him/herself, took another step, lost his/her balance and fell. Patient did not hit his/her head. The wheelchair alarm was not in place. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
d. On 2/26/25 at 1745 hours P2 fell out of his/her wheelchair witnessed by staff. The patient verbalized no pain and reported he/she just slid out of the chair. The patient was currently on Eliquis (a blood thinner which can cause bleeding) and per policy the patient is to be a medical send out to be evaluated. Patient had no visible injuries or pain. MR lacked documentation of patient sent to the ED. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
e. On 2/27/25 at 0553 hours patient slid from his/her wheelchair to his buttocks with no injuries. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
f. On 2/27/25 at 1907 hours patient was screaming, yelling and seeking attention. The staff were unable to redirect the patient and the patient told staff he/she would continue throwing him/herself on the floor. Related to the patients behavior he/she did stumble and fall to the floor. Patient did not hit his/her head and provider notified and ordered to keep patient in facility and monitor for changes. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls

4. Review of P3 MR indicated:
a. On 2/15/25 at 1000 hours the patient had an unwitnessed fall. The patient was found sitting on the floor in room 102. Patient stated he/she was walking to the bathroom, and his/her right foot gave out and he/she fell on the right side of his/her buttock. The patient reported no injuries. MR lacked documentation of falls risk care plan with goals and interventions to prevent further falls
b. On 2/21/25 at 1440 hours the patient was in restroom getting off of the toilet, missed the wheelchair and slid to the floor. Patient had no injuries and voiced no complaints of pain. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.

5. Review of P4 MR indicated:
a. On 6/24/25 at 0200 hours the patient was wandering around milieu all night, bending over and stepping over things that were not there. Patient was stepping over something, lost his/her balance, and fell to the floor. Patient did not hit her head and complained of slight hand pain. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.

6. Review of P5 MR indicated:
a. On 4/6/25 at 1739 hours the patient was in the room, had an unwitnessed fall and was complaining of back pain. Patient transported to ED per EMS at 1756 hours. Patient transported to ED per EMS at 1756 hours. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
b. On 4/10/25 at 1350 hours the patient was found sitting on the floor. The patient reported falling on her bottom and did not hit his/her head. No injury noted to patient. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
c. On 4/10/25 at 1640 hours upon entering the patient's room, he/she was found sitting on floor and reported he/she fell on his/her bottom. The patient denied hitting his/her head. No injuries noted. The chair alarm was placed in the wheelchair and requested an order for line of site observation. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
d. On 4/15/25 at 1225 hours the patient fell off of a table he/she was sitting on. The patient did not hit his/her head. The patient complained of pain in his/her right wrist and right hip. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
e. On 4/16/25 at 1258 hours the patient was pulling a chair and fell backwards on his/her buttocks. Patient was assisted up by two staff members and denied complaints of pain. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
f. On 4/22/25 at 2045 hours the patient was standing, talking with a peer, side stepped, lost his/her balance, landed on buttock, and rolled onto his/her left side. The patient did not hit his/her head. The patient denied pain. The patient was not wearing nonskid socks or shoes. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.

7. Review of P6 MR indicated:
a. On 4/20/25 at 1400 hours the patient fell at the end of the milieu and did not hit his/her head. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
b. On 4/20/25 at 1720 hours the staff heard the patient fall in room 111, and observed patient lying on his/her back on the floor. The patient immediately complained of head, right shoulder, and back pain. The patient was transported to ED per EMS at 1805 hours. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
c. On 4/21/25 at 1715 hours the patient fell out of his/her wheelchair and hit his/her head on a walker. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.

8. Review of P7 MR indicated:
a. On 5/14/25 at 2235 hours the patient was found in the room sitting on the floor. The patient reported he/she was going to the bathroom and fell, landing on his/her buttock. The bed alarm was not activated at the time of fall. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
b. On 5/17/25 at 0235 hours he patient tripped over another patient's legs, fell and landed on his/her right hip on floor mat. The patient did not hit his/her head. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
c. On 5/18/25 at 0450 hours the patient was found on the floor sitting by the toilet. The patient reported he/she fell off of the toilet. The patient did not hit his/her head. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.

9. Review of P8 MR indicated:
a. On 5/17/25 at 1520 hours the patient was trying to get out of the exit door, was near a wall, and slid to the floor on his/her buttocks. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
b. On 5/19/25 at 1355 hours the patient was in milieu during activity and slipped out of chair onto the floor. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
c. On 5/20/25 at 1213 hours patient was pacing around milieu and slipped and fell to the floor landing on his/her right side. No injuries noted. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
d. On 5/22/25 at 1545 hours the patient was observed on the ground by the janitor's closet. Fall unwitnessed, and patient hit his/her head on the door. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
e. On 5/23/25 at 1530 hours the patient was found on the floor in the back of the milieu. The patient sent to ED. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
f. On 5/26/25 at 1203 hours the patient was pacing and fell backwards onto his/her back in front of the nurse's station. The patient did not hit his/her head. MR lacked documentation of falls risk care plan with goals and interventions in place and/or to update to prevent further falls.
g. On 5/26/25 at 1448 hours patient was attempting to move around table and fell backwards onto buttock. Patient did not hit his/her head. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
h. on 5/27/25 at 1050 hours the patient was pushing on a table, stood, lost his/her balance and fell backwards on his/her buttock. No injuries. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.

10. Review of P9 MR indicated:
a. On 3/23/25 at 1730 hours the patient was found on the floor in his/her room. No injuries. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
b. On 3/25/25 at 0430 hours the patient was yelling and was found flat on his/her back on the floor near his/her bed. No injuries. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.
b. On 3/26 25 at 2100 hours the bed alarm was sounding and the patient was found lying flat on his/her back on the floor. No injuries. MR lacked documentation of falls risk care plan with goals and interventions in place to prevent further falls.

11. Review of P10 MR indicated:
a. On 7/4/25 at 0653 hours the patient was found on the floor in his/her room. The patient reported hitting his/her head and complained of shoulder and right knee pain. The patient transported to ED. Care plan with goal, lacked interventions and/or updated interventions to prevent further falls.
b. On 7/7/25 at 2315 hours incident report indicated patient fell in his/her room. No injuries noted. Patient put to bed to sleep with bed alarm set. Care plan with goal, lacked updated interventions to prevent further falls.

12. In interview on 7/15/25 at 1300 hours with A1 (Nurse Consultant), he/she confirmed P1, P2, P3, P4, P5, P6 P7, P8 and P9 do not have a falls risk care plan filled out with interventions and goals individualized for each patient to prevent further falls/injury. A1 also confirmed P10 had a care plan with a goal, but lacked interventions and or updates to the careplan to prevent patient from further falls/injury.

Based on document review and interview, nursing services failed to develop a falls risk care plan with goals and interventions in 10 of 11 MR's (Medical Records) reviewed. (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10)

Findings include:

1. Facility policy titled Nursing Assessment of Patients, Policy No.: NU 09, Revised 6/2025, Page 1, under Policy: All patients admitted to this Hospital will be placed on fall prevention protocol. Interventions. p) Falls NANDA (the nursing diagnosis Risk for Falls care plan) for every patient. Post Fall Investigation: 4. Upon review, environmental and human factors that are deemed of modification, education, counseling etc. will be implemented.

2. Review of P1 MR (Medical Record) indicated:
a. Patient had falls on 6/7/25, 6/11/25, 6/14/25, 6/15/25 x 2 falls and 6/16/25.
b. MR lacked documentation of care plan for falls or care plan update.

3. Review of P2 MR indicated:
a. Patient had falls on 2/19/25, 2/22/25, 2/25/25, 2/26/25, and 2/27/25 x 2 falls.
b. MR lacked documentation of care plan for falls or care plan update.

4. Review of P3 MR indicated:
a. Patient had falls on 2/15/25 and 2/21/25.
b. MR lacked documentation of care plan for falls or care plan update.

5. Review of P4 MR indicated:
a. Patient had a fall on 6/24/25.
b. MR lacked documentation of care plan for falls or care plan update.

6. Review of P5 MR indicated:
a. Patient had falls on 4/6/25, 4/10/25 x 2 falls, 4/15/25, 4/16/26 and 4/22/25.
b. MR lacked documentation of care plan for falls or care plan update.

7. Review of P6 MR indicated:
a. Patient had falls on 4/20/25 x 2 falls and 4/21/25.
b. MR lacked documentation of care plan for falls or care plan update.

8. Review of P7 MR indicated:
a. Patient had falls on 5/14/25, 5/17/25 and 5/18/25.
b. MR lacked documentation of care plan for falls or care plan update.

9. Review of P8 MR indicated:
a. Patient had falls on 5/17/25, 5/19/25, 5/20/25, 5/22/25, 5/23/25, 5/26/25 x 2 falls and 5/27/25.
b. MR lacked documentation of care plan for falls or care plan update.

10. Review of P9 MR indicated:
a. Patient had falls on 3/23/25, 3/25/25 and 3/26/25.
b. MR lacked documentation of care plan for falls or care plan update
.
11. Review of P10 MR indicated:
a. Patient had falls on 7/4/25 and 7/7/25.
b. Care plan had a goal, lacked documentation of interventions or care plan update related to falls.

12. In interview on 7/15/25 at 1300 hours with A1 (Nurse Consultant), he/she confirmed P1, P2, P3, P4, P5, P6 P7, P8 and P9 do not have a falls risk care plan filled out with interventions and goals individualized for each patient to prevent further falls/injury. A1 also confirmed P10 had a care plan with a goal, but lacked interventions and or updates to the careplan to prevent patient from further falls/injury.