Tristar Southern Hills Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 51739 Based on policy review, hospital video review, medical record review, and interview, the facility failed to ensure patients presenting to the Emergency Department (ED) were provided a medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 1 of 6 (Patient #1) sampled patients who presented to Hospital #1. The findings included: 1. Medical record review revealed Patient #1 presented to the ED at Hospital #1 on 9/10/2025, via “police” at 4:11 PM with a signed Certificate of Need for Emergency Voluntary Psychiatric Admission (6404- a document used in the involuntary commitment process for individuals who pose an immediate substantial likelihood of serious harm due to a mental illness or emotional disturbance). Patient #1’s presenting chief complaint was Homicidal Ideation (HI -thoughts about killing someone). Patient #1 was not triaged and was not designated a number rating for Emergency Severity Index (ESI-a triage system used in the emergency departments to classify patients based on their severity and resources needed). Review of the “History of Present Illness” written by Medical Doctor (MD) #1 at Hospital #1 dated 9/10/2025 at 4:15 PM, revealed “...history of Bipolar Disorder, Schizophrenia, Depression with frequent inpatient hospitalizations who is here due to homicidal ideation. She has been escalating over the past few days, was seen yesterday for an altercation as well, then today [Patient #1] started threatening violence on her roommates in the group home that she is in as well as caregivers there [at the group home], so she [Patient #1] was brought back to the emergency department for evaluation. No medical complaints at this time...” Review of the “Physical Examination” written by Medical Doctor (MD) #1 at Hospital #1 revealed, “ ...[the patient was] agitated, nontoxic appearing and in no respiratory distress. Pupils equal round and reactive to light. Conjunctiva clear. Moist mucous membranes. Neck supple and nontender. Cardiovascular regular rate and rhythm. Nonlabored breathing...” Review of the “Hospital Security Footage” from Hospital #1 dated 9/10/2025 from 4:11 PM-4:37 PM, revealed the patient was not examined by either a doctor or nurse. The video footage revealed Patient #1 and two Police Officers (PO) #1 and #2 entered Hospital #1’s ED on 9/10/2025 at 4:11 PM and were seen leaving Hospital #1’s ED at 4:31 PM. Review of the “Medical Decision-Making Note” written by MD #1 at Hospital #1 dated 9/10/2025 at 6:15 PM, revealed, “...patient arrived to the emergency department [at Hospital #1] with chief complaint of homicidal ideation, aggressive behavior. Patient was seen and examined by myself in the emergency department. She was here with two police officers, spoke with the mobile crisis team and they had placed her under 6404, she was threatening to assault staff and started kicking windows and damaging hospital property, continued to make aggressive statements. She did not endorse any suicidal ideation, had no medical complaints, labs [laboratory testing; blood work] and medications were ordered but she would not consider this so she was discharged to jail for medical clearance there...” Review of the medical record from Hospital #2 revealed after leaving Hospital #1’s ED with the PO #1, Patient # 1 presented to Hospital #2 on 9/10/2025 at 5:45 PM with a chief complaint of medical clearance for admission and treatment to a behavioral health facility. Cross Refer to A-2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 51739 Based on policy review, medical record review, hospital video footage, and interview, the hospital failed to ensure patients presenting to the Emergency Department (ED) for medical treatment were provided an appropriate Medical Screening Exam (MSE) to determine if an Emergency Medical Condition (EMC) existed for 1 of 6 (Patient #1) sampled patients who presented to Hospital #1’s ED. The findings included: 1. Review of the facility’s policy titled “Tennessee EMTALA [Emergency Medical Treatment and Labor Act]-Medical Screening Examination and Stabilization” revised 5/18/2022, revealed, “...PROCEDURE: 1. When an MSE is required... f. If a law enforcement official requests hospital emergency personnel to provide medical clearance for incarceration the hospital has an EMTALA obligation to provide an MSE to determine if an MSE exists ...” Review of the facility’s policy titled “Suicide Risk Assessment for Patients in Non-Behavioral Health Setting” revised 8/8/2023, revealed, “... it is the policy of [named Hospital #1] to create an environment of care that will foster the assessment, identification, and management of patients who are at increased risk for suicide or self-harming behaviors. Patients who are at an increased risk for suicide or self-harming behaviors require intensive support, close observation, and frequent reassessment for their emotional and physical well-being. The scope of this plan begins at triage, prior to admission to the hospital, and continues until the patient is discharged ...PROCEDURE: A. The nursing assessment will include current, recent, and past thoughts of suicide, plans, means and/or intent, as well as recent or past history of suicide attempts within their lifetime for patients aged 12 and above being admitted to ER’s (Emergency Rooms) ...D. The Provider/Practitioner will reassess at risk patients daily and as needed with a change in patient condition. The Provider/Practitioner will coordinate care with the patient’s nurse to ensure the appropriate environment of care and suicide risk mitigation strategies are implemented according to the overall risk level ...F. If the suicide risk screen cannot be completed upon presentation to the ER or upon admission to an inpatient unit because of the patient’s condition the screening will be completed once the patient’s condition improves. Then the patient care team will take next steps to implement the appropriate safety precautions and risk mitigation strategies as determined by the patient’s level of risk ...” 2. Medical record review revealed Patient #1 presented to Hospital #1’s ED on 9/10/2025 at 4:11 PM, via “police” with a signed Certificate of Need (CON) for Emergency Voluntary Psychiatric Admission (6404 - a document used in the involuntary commitment process for individuals who pose an immediate substantial likelihood of serious harm due to a mental illness or emotional disturbance.) Patient #1’s presenting chief complaint was Homicidal Ideation (HI - ideas/thoughts of killing others). There was no documentation Patient #1 was triaged or assigned an Emergency Severity Index rating (ESI-a triage system used in the emergency departments to classify patients based on their severity of symptoms and resources needed). Review of Hospital #1’s “History of Present Illness” written by Hospital #1’s Medical Doctor (MD) #1 dated 9/10/2025 at 4:15 PM, revealed “...[the patient had a] history of Bipolar Disorder, Schizophrenia, Depression with frequent inpatient hospitalizations who is here due to Homicidal Ideation (HI). She has been escalating over the past few days, was seen yesterday for an altercation as well, then today [Patient #1] started threatening violence on her roommates in the group home that she is in, as well as caregivers there, so she was brought back to the emergency department for evaluation. No medical complaints at this time ...” Review of “Physical Examination” written by Hospital #1’s Medical Doctor (MD) #1, dated 9/10/2025 with no documented time, revealed, “...agitated, nontoxic appearing and in no respiratory distress. Pupils equal round and reactive to light. Conjunctiva [the thin, transparent membrane that covers the white part of the eye and lines the inside of the eyelids] clear. Moist mucous membranes. Neck supple and nontender. Cardiovascular regular rate and rhythm. Nonlabored breathing ...” Review of Hospital #1’s Security Video Footage” dated 9/10/2025, revealed the following: 4:11:21 PM - Patent #1 entered the ED with her hands behind her back in handcuffs accompanied by 2 Police Officers (PO #1 and #2). Registered Nurse (RN) #1 and MD #1 were observed sitting behind the nurse’s desk. 4:12 PM - Patient #1 was pacing the floor and walking in circles in front of the ambulance entrance in a nonaggressive manner while multiple staff and patients passed by. RN #1 left the nurses station for a total of 4 minutes while MD #1 remained seated. 4:13:23 PM - PO #2 walks toward the ED entrance doors and Patient #1 walked to the nurses station. MD #1 remained seated at the nurses station. 4:20 PM - PO #1 exited the ED’s ambulance entrance. MD #1 remained seated at the nurses station. 4:23 PM - Patient #1 was pacing in front of the nurses station. MD #1 was seated at the nurses station. 4:24 PM - Patient #1 was talking to PO #2. MD #1 was seated at the nurses station. 4:24:31 PM - RN #1 exited the nurse’s desk and walked close to Patient #1. 4:24:37 PM - Patient #1 walked closer to RN #1. 4:24:40 PM - PO #1 was holding Patient #1 by the handcuffs. Patient #1 made a lunge at RN #1 but made no contact with RN #1. Patient #1 continued talking to RN #1 with her head moving from side to side. MD #1 remained seated at the nurses station. 4:24:50 PM - RN #1 moved a few steps to the right and pointed over her left shoulder while she continued to talk with Patient #1. 4:24:54 PM - Patient #1 kicked the nurse’s desk 1 time while PO #1 held the patient by the handcuffs. 4:25:11 PM - PO #1 pulled Patient #1 backward a few steps and patient #1 leaned against the wall. Hospital Security (HS) #1 entered the area where Patient #1 and PO #1 were standing. Another person, known as a Blue Line (contracted security guard) entered the area and stood at the right side of Patient #1 and PO #1. MD #1 was seated at the nurses station. 4:26:55 PM - Patient #1 kicked the wall next to the ambulance entrance 1 time. Patient #1 was moved to the opposite side by PO #1. The patient attempted to kick PO #1 and PO #1 and the Blue Line guard pushed the patient into the glass breakaway door of Emergency Department room #2. MD #1 was seated at the nurses station. 4:27:02 PM - Patient #1 was standing in front of ED’s entrance doors with PO #1 and Blue Line on each side of the patient. There was no aggressive behavior at this time. MD #1 was seated at the nurses station. 4:29 PM - HS #1 approached RN #1 and MD #1 at the nurses’ desk, then returned to Patient #1 and PO #1. MD #1 was seated at the nurses station. 4:31 PM - After a short discussion, Patient #1 and PO #1 exited the ED through the ambulance entrance. HS #1 approached RN #1 was given paperwork by RN #1. MD #1 was seated at the nurses station. 4:32 PM - HS #1 exited through the ambulance entrance carrying paperwork and returned to RN #1 and MD #1. MD #1 was seated at the nurses station. Review of the Hospital Security Footage dated 9/10/2025 from 4:11 PM - 4:37 PM, a total of 26 minutes Patient #1 was in the ED of Hospital #1, revealed Patient #1 was not examined by either a doctor or nurse while in the Emergency Department at Hospital #1. Review of the “Medical Decision-Making Note” written by Hospital #1’s MD #1 dated 9/10/2025 at 6:15 PM, revealed, “...patient arrived to the emergency department with chief complaint of homicidal ideation and aggressive behavior. The patient was seen and examined by myself in the emergency department. She was here with two police officers, spoke with the mobile crisis team and they had placed her under 6404, she was threatening to assault staff and started kicking windows and damaging hospital property, continued to make aggressive statements. She did not endorse any suicidal ideation, had no medical complaints, labs [laboratory testing; blood work] and medications were ordered but she would not consider this so she was discharged to jail for medical clearance there...” 3. Review of the medical record revealed Patient # 1 presented to Hospital #2 on 9/10/2025 at 5:45 PM with a chief complaint of medical clearance for behavioral facility. Review of the “History of Present Illness” from Hospital #2 dated 9/10/2025 at 6:53 PM, revealed, “...Patient is a resident of a group home with history of bipolar disorder presenting to the emergency department accompanied by mobile crisis for psychotic behavior. Patient was apparently making threats to other individuals at her group home. She was threatening to stab them and stated that she was going to kill everybody. She arrives with 6404 in place by mobile crisis. Patient is currently awaiting placement. It sounds like she was at [named Hospital #1] at some point on 2 different occasions within the past 24 hours and was making threats to staff there as well ...” Review of the “Care Management Note” from Hospital #2 dated 9/10/2025 at 9:04 PM, revealed, “...patient presents via police and crisis with a signed 6404 for homicidal ideation. Per crisis, they attempted to take patient to [named Hospital #1] for medical clearance, but [named Hospital #1] refused to take patient. Per crisis, patient has been accepted pending medical clearance, Patient’s crisis assessment reports that patient has HI towards her group home members, and pulled a knife on one of them yesterday...” 4. During an interview on 9/22/2025 at 10:30 AM, (Hospital #1’s) RN #1 stated, “... as soon as she [Patient #1] came in, I got to talk to her [Patient #1], and she [Patient #1] tried to headbutt me and then she kicked the glass at the nurse’s station... police could not tell me why she [Patient #1] was here or give me any reason. Mobile Crisis never came with her [Patient #1], and they never sent the 6404 or anything...That day, we were very busy. We had 44 people [patients] in our department [Emergency Department of Hospital #1]. I told them [Police Officers] that we didn’t have a bed, that they would have to wait with her [Patient #1] or they could take her to jail, and they [Police Officers] chose to go to jail. They [Police Officer] took the 6404 with them and took her [Patient Officer] to jail. The police said, ‘you seriously don’t have anywhere to put her’. I told him [Police Officer] we have one seclusion room for violent patients, and somebody was already in it. Mobile Crisis saw her [Patient #1] in the field. Nobody from Mobile Crisis came in or gave report. The Police Officer said, “well, I faxed the 6404...” During an interview on 9/22/2025 at 10:35 PM, Hospital #1’s ED Nurse Leader stated, “...I remember the situation, but I know that RN #1 was in room 14 and she had nothing to do with the patient ...We do not have a truly dedicated space or security for psych patients. We do have a sitter that sits with them ...all patients are triaged when they come into the emergency room and then when a bed is available, they put them in a room ...if they are brought by police or EMS [Emergency Medical Services] they [police or EMS] stay with them until we have a room or a hall bed is available ...no one is ever turned away ...” During a telephone interview on 9/22/2025 at 11:30 AM, Crisis Counselor #1 stated, “...I am a supervisor with mental health cooperative. Specifically, one of the programs that runs with the Police Department... We had the police take her to [named Hospital #1]. I had written emergency committal over her [Patient #1], a 6404, because she [Patient #1] was homicidal... She [Patient #1] was attempting to kill members of her group home and her [Patient #1’s] nurse practitioner... [named Patient #1] actually signed the papers but I took over the scene because of some personal stuff that was going on with [named Patient #1]...So we put her [Patient #1] in the back seat of a police car and transported her, but at no time was she [Patient #1] under any arrest... [named Hospital #1] said that they wasn’t going treat her [Patient #1], so the officer left because she [Patient #1] was under a 6404. She [Patient #1] had to go somewhere for medical clearance. The police took her from [named Hospital #1] straight to another hospital [Hospital #2]. I called and gave report to the doctor. He was fully aware of the situation and what was going on, as was the charge nurse. I don’t remember the doctors name... The officers were calling me and talking to me about what was going on. The officer called me and was very confused. In between the time of them [Police] giving report via the phone and maybe 10 minutes she [Patient #1] escalated in the emergency room. She was mean, she was homicidal. She was not happy. I think that just kind of comes with folks that are homicidal. I truthfully don’t know what happened, but I know that something happened to where the doctor and the charge nurse said that they were not going to provide treatment, that she needed to go somewhere else...the Police Officer took her [Patient #1], put her back in the back seat of his car and called me and said, “I don’t know what to do...They did not rescind the 6404. They did not check her in at all.” And I said, OK, well let’s go to a different hospital. I’ll figure this out later. She has to go to a hospital...” During an interview on 9/22/2025 at 2:00 PM, Hospital Security #1 stated, “...My job is to protect the staff from patients that are making comments or statements that could be threatening...The nurse said the patient was too aggressive and they weren’t going to see her. I was just relaying the information to the police officer. When they left the nurse gave me some paperwork to give the officer, so I did...” During a telephone interview on 9/22/2025 at 3:12 PM, the ED Medical Director of Hospital #1 stated, “...We provide a medical screening exam [examination] on all psych [psychiatric] patients and once they are medically clear, we have a psychiatry team look at them...I think I remember her [Patient #1] coming in. I didn’t take care of her, but I believe I was there that day...I will tell you that when people come in through the door we sit right where they come in, we can see them come in. We have pretty good viewpoint for just a general assessment, but as far as when we do medical screening exams, we examine the patient, we listen to their heart and lungs as soon as we possibly safely can, we do that. That has to be done. We have to get close enough to the patient to be able to do that and there’s no way around that...” During a telephone interview on 9/23/2025 at 2:22 PM, Hospital #1’s Medical Doctor (MD) #1 stated, “...I took a call from mobile crisis, talked to them, and was told they placed the patient under 6404...the police brought her in and I saw her she was a little too violent for me to do my normal stuff on her...I can do an assessment just by looking at a patient. If I can’t approach a patient because they are violent, I will do an assessment from afar for my own safety and my staff safety...” During a telephone interview on 9/23/2025 at 2:26 PM, Hospital #1’s MD #2 stated, “...it was my signature rescinding the 6404, but none of this makes sense I work 6:00 PM to 6:00 AM and so the patient wasn’t even in our department at all when I was there...I don’t remember, I mean we have so many of these on a daily basis it is kind of crazy and hectic... we have so many psych patients and they move around constantly because they will be calm in the hallway and then moved to a room and then they are not calm and they will get put in an isolation room. So, the patient moves constantly but the 6404 or 6401 does not follow them in the chart. It could have been somebody else’s [another patient’s paperwork] that I thought I was signing...Or the case was that bookkeeping said this needs to be signed...Almost on a nightly basis we have psych patients who are violent or screaming obscenities. In that case you either have to try and calm them down or medicate them and assess them later...there are times where you are scared to evaluate a patient for safety of yourself and staff and the patient but you cannot evaluate a patient on the other side of the nurse’s desk. You have to lay your hands and a stethoscope on them...worst case scenario, we would document patient was not being cooperative unable to assess such and such...I would chart patient is extremely uncooperative unable to perform exam...” During a telephone interview on 9/23/2025 4:00 PM, at PO #1 stated, “...they looked at her 6404 paperwork, that’s as far as I would know about them getting her into the facility. The nurse was mad at us off the get go when we got there for some reason. The lady that was sitting at the computer right at the front, was not happy about us being there. All they told me was they were looking; they were trying to get a room for her...The other officer left because she [Patient #1] was fine, and I didn’t think anything was going to happen and then she [Patient #1] started getting all rowdy...We were standing there for a long time and then she [Patient #1] started getting all agitated. After she kicked the glass, the nurse said, “we’re not going to take her if she’s like that”. I told her [the nurse] the patient was under 6404 and she said, “well, they could do all that in jail”. I have no idea who made that decision, but the nurse was the one who communicated it. The nurse that was sitting right at the front said it. After she [the nurse] said that, I stood there with her [Patient #1] for like another 15-20 minutes. Eventually the security guard came over and said, “yeah, they’re not going to take her”. She [Patient #1] didn’t come in contact with any nurses to my knowledge. She [Patient #1] wanted everything to hurry up. I don’t think she [Patient #1] threatened anyone. I know the nurse walked up to her [Patient #1] once, at one point and they just kind of stood next to each other, and faced each other and she [Patient #1] yelled but there was no contact made or anything. She [Patient #1] was not a threat to the staff members in the emergency room. I don’t remember if they [Hospital #1’s staff] took her [Patient #1’s] vitals or anything and especially a physician didn’t talk to her. After they [Hospital #1’s staff] told me they were not going to take her [Patient #1], I basically took her out and I called [named Case Worker] and I said they [Hospital #1] were refusing to take her [Patient #1] and she said, alright, we can go to another hospital. So, I took her to another hospital [Hospital #2]...””

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 37530 Based on policy review, medical record review, and interview, the facility failed to ensure the patient’s legal representative was notified with a change in condition for 2 of 3 sampled patients (Patient #1 and #12) reviewed for falls. The findings included: Review of the policy titled “Patient Fall Prevention Program,” dated 12/4/2023, revealed “...PURPOSE...Establish post-fall huddle and Serious Safety Event (SSE) reporting guidelines ...Notification of the fall...At a minimum, the Attending Physician, Nursing Leader, and patient legal representative will be notified as soon as possible...” Review of the medical record revealed Patient #1 was admitted on 10/27/2022 with diagnoses that included Delirium, Pneumonia, Diabetes, Hypertension, Atrial Fibrillation, Kidney Transplant, and Chronic Kidney Disease. Review of the “Nurse Note,” dated 11/9/2022, revealed “...PT [patient] ATTEMPTED TO GO TO THE BATHROOM UNASSISTED, BATHROOM CALL LIGHT GOING OFF. TECH [technician] WENT TO ROOM AND HEARD PT YELLING FOR HELP. TECH GOT HELP AND GOT PATIENT TO FEET AND BACK TO BED. GRIP SOCKS ON FEET AT TIME OF FALL. WHEN ASKED WHAT HAD HAPPEN, PATIENT STATED HE NEEDED TO USE THE BATHROOM AND LOST BALANCE AND FELL BACKWARD...” Review of the “Progress Note,” dated 11/11/2022, revealed “...Called niece, [Named family Member #2], and updated her on his care, She was aware of the fall via Air Ambulance...” The facility failed to complete a Post-Fall debrief and an incident report for Patient #1. The facility failed to list Patient #1 on the fall log dated November 2022. During an interview on 3/18/2025 at 10:36 AM, the Vice President Quality/Risk was asked if there was an incident report completed for Patient #1’s fall on 11/9/2022. The Vice President Quality/Risk confirmed there was no incident report or post fall debriefing tool completed for the fall on 11/9/2022. The Vice President Quality/Risk was asked should the legal representative be notified after each fall. The Vice President Quality/Risk confirmed the family should be notified after each fall. Review of the medical record revealed Patient #12 was admitted on 2/28/2023 with diagnoses of General Weakness, Fracture of Left Humerus, Acute Renal Failure and Hypotension. Review of the “Post-Fall Debrief Tool,” dated 3/1/2023, revealed “...Pt [patient] tech [technician] told this nurse pt was in bathroom & [and] would use call light when done in restroom. A few minutes later...[Name Tech] came to me at nurse desk & reported pt fell, used call light but lost his balance...” During an interview on 3/1/2025 at 2:33 PM, the Vice President Quality/Risk when reviewing Patient #12’s incident report was asked if the legal representative was notified during the fall incident on 3/1/2023. The Vice President Quality/Risk confirmed the legal representative was not notified after the fall that occurred on 3/1/2022. During an interview on 3/18/2025 at 3:45 PM, Registered Nurse (RN) #1 was asked what was the procedure for when a patient fell. RN #1 stated, “...We inform the doctor...write a report [post fall debrief]...check the patients vital signs...have the witness help get the patient up to the chair...make sure the patient is okay...inform the nursing supervisor...complete the post fall debrief...notify the family...” RN #1 was asked where nursing documented that the family was notified. RN #1 confirmed she would document the notification of the family in the fall interventions and in her notes. The facility failed to notify the patient’s legal representative after each fall.”