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Based on interview and record review, the facility failed to ensure the facility's policy and procedure was followed, for two of 30 sample patients, when:

1. Patient 2, who was a high risk for falls, had a fall when he was left unattended in the bathroom resulting in injury.

This failure in Patient 2 sustaining bleeding and abrasion on the head and being sent to the Emergency Department; and

2. For Patient 16, the malfunction of the patient's hospital bed was not acted upon timely.

This failure had the potential to compromise the safety of Patient 16.

Findings:

1. On February 18, 2025, at 9 a.m., an interview and concurrent facility tour were conducted with the Chief Executive Officer (CEO). The CEO stated "Red Charm" patients are patients who are high risk for falls. He further stated "Red Charm" patients cannot be left unattended.

On February 18, 2025, at 9:30 a.m., an observation was made of room 125's bathroom. A sign next to the toilet was observed. The sign indicated, "If I have a red charm stay with me."

On February 18, 2025, at 1:15 p.m., the undated facility document titled, "Patient Safety Color Charm System," was reviewed with Chief Nursing Officer (CNO). The document indicated, "...Red Band Charm - HIGH RISK, POOR SAFETY...Safety judgement is impaired and requires direct supervision in bathroom. Needs bed alarm and self-releasing seatbelt with alarm when in wheelchair. If left out of bed in room, chair alarm needs to be connected to wall call light system and with call light within reach. Footrests of wheelchair should be on..."

On February 19, 2025, at 10 a.m., interview and concurrent review of Patient 2's record were conducted with the Chief Nursing Officer (CNO). The facility document titled, "History and Physical," dated June 21, 2024, was reviewed. The document indicated Patient 2 was admitted to the facility on June 21, 2024, for skilled therapy treatments by physical therapy and occupational therapy.

The CNO stated all new admitted patients are deemed a "Red Charm (High Risk for Falls)." The CNO stated all patients who are newly admitted are considered a high risk for falls and would be deemed a "Red Charm." She further stated Patient 2 was considered high risk for falls and was deemed a "Red Charm." The CNO stated Patient 2 should have not been left unattended.

On February 21, 2024, at 10:12 a.m., a review of facility document titled, "Post Fall assessment," dated June 23, 2024, was conducted with the CNO. The document indicated, "...Evaluation...Pt [Patient 2] was transferred by CNA [certified nursing assistant] with walker to toilet. Pt used call light but did not wait for CNA to assist...Pt stand [sic] and did a step and feeling weakness [sic] bilateral [both] legs and fell and hit head on the floor. Pt had some bleeding on head. CNA called code STOP [Stop Think Organize Position, hospital code that is called when a patient falls]. All nurses came and assist [sic] pt...Called 911 and paremedics [sic] arrived and provided assitants [sic] and took pt to ER [emergency room]. Date/Time of Fall: 06/23/2024 [June 23, 2024] 15:35 [3:35 p.m....Fall...Unwitnessed...Bathroom...Activity at Time of Fall...Toileting...Provider Requested Interventions: Other: pt transferred to ER...Type...Abrasion...Location...head..."

On February 21, 2025, at 11:43 a.m., a review of facility document titled, "Daily Assignment Sheet," dated June 23, 2024, day shift (7 a.m. - 7 p.m.) was conducted with the CNO. The document indicated there were two CNAs assigned to 45 patients. The CNO stated there should have been four CNAs on the floor.

On February 21, 2025, at 11:45 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated if a patient had a "Red Charm," staff would assist patient to the bathroom, and they would have to stay with them. She stated a "Red Charm" patient could not be left unattended.

On February 25, 2025, at 2:45 p.m., an interview was conducted with CNA 1. CNA 1 stated a "Red Charm" patient was a patient who was high risk for falls. CNA 1 stated a "Red Charm" patient would have to be escorted to the bathroom and staff would need to stand in the bathroom with them. She stated she took Patient 2 to the bathroom in room 209 on February 21, 2025. She stated she did not see Patient 2's "Red Charm" wrist band. She stated Patient 2 stated he was an "Orange Charm" patient. She stated she left Patient 2 in the bathroom and instructed Patient 2 to use the cord call light when he was ready. She stated she should have looked at Patient 2's "Red Charm' wrist band.

A review of the facility policy and procedure (P&P) titled, "Fall Prevention Program," dated July 26, 2024, was conducted. The documented indicated, "...Fall Prevention Program is designed to reduce the risk of falls at the hospital...Until all assessments are complete, all patients are treated at high risk for falls, usually lasting no longer than the first 24-48 hours...Admission Fall Precautions: Upon admission, plan of care for fall prevention will be initiated to include at a minimum...Supervision in the Bathroom...Precautions...Supervision in bathroom (stay with me)...On admission, all patients will receive a red charm and will then be evaluated by therapy for recommendation of the appropriate safety charm level...Red Charm - HIGH RISK, POOR SAFETY (consider High Risk intervention strategies) Safety judgment is impaired and requires direct supervision in bathroom..."

2. On February 18, 2025, at 9:30 a.m., a tour of the facility and concurrent interview was conducted with the Director of Quality and Risk Management (DQRM).

On February 18, 2025, at 11:30 a.m., an observation and interview were conducted with Patient 16 in Patient 16's room. Patient 16 stated the head of the electronic hospital bed did not go up or down since she was admitted to the facility. Patient 16 stated he reported the malfunction of the hospital bed to the occupational therapists (OT) and the registered nurses (RNs) several times. Patient 16 was observed to push the buttons on the side of his hospital bed. Patient 16's bed was observed to be stuck in an elevated position at a 45-degree angle.

On February 19, 2025, at 9:53 a.m., a review of Patient 16's record and concurrent interview were conducted with the Registered Nurse Manager (RNM). A facility document titled, History and Physical (H&P), dated February 6, 2025, was reviewed and indicated Patient 16 was admitted to the facility on February 5, 2025, with diagnoses of pain and weakness. The RNM stated the assigned RN should have been informed if a patient's hospital bed was not working and the charge nurse should have been notified by email or placement of a work order if it was due to supply needs. The RNM stated there was no documentation of a notification about a malfunctioning bed for Patient 16.

On February 19, 2025, at 10:45 a.m., an interview was conducted with the Facility Management Director (FMD). The FMD stated for non-working beds, a request should have been made through the facility's computerized maintenance software (CMS) system and then he would receive it by email and he would go and check the issue. The FMD stated he would go out right away to fix the problem or find a contractor to have the problem fixed. The FMD stated there was no work order nor report about Patient 16's hospital bed malfunction.

On February 19, 2025, at 11 a.m., an interview was conducted with OT 1. OT 1 stated if there was a complaint from a patient, they were to apologize and report the issue to the OT Director or nursing staff. OT 1 stated they would let the nurse know if any equipment was not working. OT 1 stated Patient 16's hospital bed was working the week prior but he did remember Patient 16's hospital the bed was not working at some point and reported the issue to the nurse. OT 1 stated he did not remember which nurse he gave the report to.

A review of the facility policy and procedure titled, "Medical Equipment Management Plan," dated July 26, 2024, was conducted. The policy indicated, "...the hospital will establish and maintain an equipment management program to promote the safe and effective use of equipment. Equipment planning includes identifying processes for ...Reporting and investigating equipment management plan's objectives, scope, performance, and maintenance..."