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A. Based on medical record review, document review, and staff interview, it was determined the facility failed to ensure nursing staff followed all nursing policies and procedures by failing to complete a "Post-Fall Assessment" in one (1) out of ten (10) patients reviewed (patient #1). This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A medical record review was conducted for patient #1. The patient was transferred to the facility on 01/11/22 for rehabilitation after being diagnosed with a left pontine hemorrhage with right-sided hemiparesis. On 01/19/22, at approximately 9:40 a.m., the patient suffered a fall. The rehabilitation physician was immediately present to assess the patient and stated in the progress note: "... I personally saw and examined the patient ... Instructed nursing to 911 [call emergency services] the patient to the ED [emergency department] for concern of new stroke or extension of prior stroke. The patient left the facility via ambulance on 01/19/22 at approximately 11:00 a.m. There is no nursing documentation in the medical record of a "post-fall" assessment on 01/19/22.

A review was conducted of policy titled "Fall Prevention Program," effective date 08/25/21. The policy states in part: "X.Post Fall Procedures/Management ... 2. Documentation/Follow Up The following documentation should be completed on each fall: A. Notify family/support B. The Post Fall Assessment documentation should be completed describing the fall and including the results assessment."

An interview was conducted with the Program Director on 03/14/22 at 1:20 p.m. Regarding patient #1, the Program Director confirmed there was no nursing "Post Fall Assessment" in the patient's medical record.


B. Based on medical record review, observation, and staff interview it was determined the facility failed to follow all physician orders in four (4) out of ten (10) patients reviewed (patients #1, 4, 7, and 10). This failure has the potential to cause great harm in patients receiving care at the facility.

Findings include:

A medical record review was conducted for patient #1. The patient was transferred to the facility on 01/11/22 for rehabilitation after being diagnosed with a left pontine hemorrhage with right-sided hemiparesis. On 01/13/22, the internal medicine physician evaluated the patient's CHF and stated in the progress note: "CHF... TED [thrombo-embolus deterrent] hose ordered." The order was placed for "Below the Knee Graduated Compression Stocking" on 01/13/22 at 11:33 a.m. On 01/18/22, the internal medicine physician stated in the progress note: "... TED hose have not been put on [patient #1]." There is no documentation in the medical record the "Below the Knee Graduated Compression Stockings" were ever placed on the patient.

A medical record review was conducted for patient #4. The patient was admitted to the facility on 02/28/22 for rehabilitation after an extensive hospital stay for cervicothoracic epidural abscess requiring surgery and resulting in incomplete quadriparesis. The rehabilitation physician ordered on 03/03/22 at 10:14 a.m. "Above the Knee Graduated Compression Stocking [TED hose], on for therapies prn [as needed] low blood pressure, q AM [every morning]." No parameters were listed as to blood pressure. No nursing documentation was present the TED hose were applied, or the parameters were clarified.

A medical record review was conducted for patient #7. The patient was admitted to the facility for rehabilitation on 03/02/22 after a fall resulted in a left distal femur periprosthetic fracture with additional complications. An order was placed on 03/03/22 at 7:22 a.m. for "Below the Knee Intermittent Pneumatic Compression Device." There is no documentation in the medical record the patient received the device.

A medical record review was conducted for patient #10. The patient was admitted to the facility for rehabilitation on 01/18/22 after a hospital stay for acute stroke of right frontal/parietal/pons and left occipital lobes resulting in significant deconditioning. On 01/25/22, a progress note by the rehabilitation physician states: "... Have ordered compression stockings for his left lower extremity edema." The order was placed on 01/25/22 at 11:58 a.m. for "Below the Knee Graduated Compression Stocking." No nursing documentation was present in the medical record that the compression stockings were applied. On 01/30/22, a progress note by the rehabilitation physician states, "... Have reordered compression stockings for [patient #10] left lower extremity edema." No nursing documentation was present in the medical record that the compression stockings were applied.

An observation was conducted of patient #7 on 03/15/22 at 10:10 a.m. The patient was in the patient room, sitting in a wheelchair at the side of the bed. There was no compression device machine visible in the room. The patient care technician stated, "I think that hurt [patient #7] legs, so we took it out." The registered nurse caring for the patient was unaware of the order.

An interview was conducted with the Program Director on 03/14/22 at 1:20 p.m. Regarding patient #1, the Program Director confirmed there was no documentation in the medical record the below the knee compression stockings were applied to the patient.

An interview was conducted with the Nurse Manager on 03/16/22 at 8:30 a.m. The Nurse Manager confirmed for patient #4 and patient #10, there was no documentation in the medical record the compression stockings were ever placed on the patients. Regarding patient #7, the Nurse Manager confirmed there was no documentation in the medical record that the sequential compression device was ever placed on the patient.