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Based on record review, and interview, the hospital did not ensure that the registered nurse (RN), supervised and evaluated the nursing care for 1 of 10 patients (Patient #1), in that, after Patient #1's fall, the RN did not follow the hospital's "Fall Policy," and/or follow standard nursing practice, as she: A) Did not document Patient #1's vital signs in the medical record, B) did not notify the physician of Patient #1's fall, and C) did not notify the family of Patient #1's fall.

Findings included:

Medical Record review of Patient #1 revealed the following:

Patient #1 had undergone a THR (total hip replacement) of her right hip at Hospital A on 5/13/13, and was then transferred to this facility (Hospital B), to be admitted for rehabilitation on 5/15/13.

-Physician Orders on admission by the physician (Personnel # 9), included: "Activity: Ambulate with assistance, Weight bearing status: partial weight bearing, Safety: Fall protocol, Precautions: Hip."

-Nurse's Notes, by the Night Shift RN (Personnel # 7), documented at 01:45 AM on 5/18/13, she "went to Pt. room with PCT (patient care technician) (Personnel # 8). Pt. sidding on floor bed, confused, Pt. stated she fell by sink. I ask how did she get back to side of her bed? Pt. stated she slide on floor, Pt. also stated she fell over by the desk in room, as Pt. was in floor, assessment was done, no injury observed. Assessed. Pt. back to bed, re-assessed Pt., no injury noted, vital signs taken. Bed alarm on, instructed Pt. to call for assistance."

A) The "Graphic and I & O (Intake & Output)" form, had no documented vital signs taken at the time of Patient #1's fall at 01:45 AM on 5/18/13.

B) There was no documentation found in the medical record, that the RN (Personnel #7), had notified the physician of Patient #1's fall.

C) There was no documentation found that Patient #1's family had been notified of her fall.

The facility's "Fall Prevention" policy, last reviewed 04/2012, revealed the following:
The "Fall Occurrence Management" process noted that "if the patient is found on the floor, a full assessment should be done prior to moving the patient ...and follow the "Fall Occurrence Algorithm," which includes: "Post-Fall Management- Nursing: 1) assess for injury including ROM (range of motion), LOC (loss of consciousness), pain laceration, bruises, etc., 2) assess vital signs and mental/neurological status, 3) assess level of injury, 4) notify the physician to examine patient and to obtain orders for follow-up care as needed, 5) monitor patient per physician orders, 6) assess and document a new Fall Assessment, 7) notify the CNO (Chief Nursing Officer)/Nursing Supervisor, 8) document in the patient's medical record, 9) notify the family, 10) complete the Post-Fall Assessment form, and 11) complete the Incident Report and the Post Fall Incident Report Addendum."

In a telephone interview at 10:00 AM on 9/04/13 with Personnel #7, she confirmed that she was the night shift nurse caring for Patient #1 the early morning of 5/18/13. Personnel #7 said when Patient #1 had fallen in her room, she had "checked to see if anything hurt, and then examined her while she was on the floor, to determine if there was any injury before moving her." When asked if she had done any vital signs, she stated that "she did not remember doing vital signs, but they would have been done by the PCT." When asked what other things she had done, she said that she "had documented a re-assessment after the fall, and that she did put the bed alarm on the bed." She said she "could not remember doing anything else, that "no doctor was notified, as the patient was ok, and that she did not remember calling the family."

In a telephone interview at 9:15 AM on 9/05/13 with Patient Care Technician (PCT) (Personnel #8), she confirmed she was on duty when Patient #1 fell at 01:45 AM on 5/18/13. When asked if she had obtained Patient #1's vital signs, Personnel #8 said " that is very possible, but that she did not remember. "

In a telephone interview at 10:15 AM on 9/05/13 with the RN, House Supervisor on Night Shift (Personnel #5), she confirmed she was on duty at the time of Patient #1's fall, and had been one of the nurses who responded. When asked if they had notified a doctor, she said that " the primary nurse should have called the doctor, but she didn't know for sure if that was done. "

In an interview at 3:35 PM on 9/03/13 with the RN, House Nursing Supervisor on Day Shift (Personnel #4), she verified that she had personally interviewed Patient #1, later in the morning after her fall, and had documented Patient #1's information. Personnel #4 said she had performed a follow-up investigation process, and found from chart review, that "no vital signs were taken, no family called, and no doctor was notified." Personnel #4 stated that she had spoken to Personnel #7, the RN on duty that night, about incomplete documentation.