Kindred Hospital - Chicago

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 34411 Based on document review and interview, the Hospital failed to comply with the Condition of Participation 42 CFR 482.23 Nursing Services. Findings include: 1. The Hospital failed to ensure fall prevention measures were in place; completion of a fall risk assessment post-fall; and that care plans were updated to include post-fall interventions. See deficiency at A-395.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 34411 Based on document review and interview, for 13 of 14 (Pt #1, Pt #4, Pt #5, Pt #6, Pt #8, Pt #9, and Pts #13-#17, Pt #18, and Pt #19), clinical records reviewed for fall precautions and falls, the Hospital failed to ensure fall prevention measures were in place; completion of a fall risk assessment post-fall; and that care plans were updated to include post-fall interventions. Findings include: 1. The Hospital’s policy titled, “Fall Prevention” (dated 5/2025) was reviewed and required, “At the time a fall risk screen is completed, appropriate fall intervention precautions are initiated ...Patients are re-screened for fall risk with a change in condition (i.e., change in cognition, after a fall) and/or change in medication(s) that could affect fall risk, and weekly (no more than seven calendar days between screenings) ...Procedure: A score of 6-13 total points=Moderate Fall Risk ...Implement bed and/or chair alarms ...A score of >13 total points=High Fall Risk. The High Fall Risk Interventions may include, but are not limited to: Low Fall Risk and Moderate Fall Risk Interventions: Protective devices such as mats on the floor ...” 2. The “Fall Investigation/Huddle Worksheet” (dated 5/2016), was reviewed and required, “Post Fall Requirements ...Fall Care plan updated ...” 3. The clinical record of Pt. #1 was reviewed on 12/15/2025. Pt. #1 was admitted to the Hospital’s A campus 03/26/2025 at 7:39 PM with a diagnosis of acute respiratory failure. - The initial fall risk assessment, dated 03/28/2025 at 10:58 AM, included a score of 11 (Moderate Fall Risk) [High Fall Risk: > 13; Moderate Risk: 6-13; Low Risk: 0-5]. Subsequent weekly fall risk screenings starting from 04/01/2025-04/29/2025 (last screening documented) included, “Patient is deemed high fall risk due to a diagnosis that places patient at risk. Fall risk level: high.” - Fall safety precautions documented on 04/30/2025 at 10:42 AM included side rails up x3, bed position low, call light within reach. - A Nurse’s Note (E#10) on 04/30/2025, included “Patient showing signs of restlessness building up. [This RN/Registered Nurse] planned to give Ativan, but patient climbed out of bed and fell over pulse oximeter. [This RN] was coming into the room anyways and assessed immediately, patient axo [alert and oriented x2] at baseline. Patient attempting to get out of bed to see if there were ‘snacks in the closet.’ Patient had minor abrasion on elbow from fall. MD [Medical Doctor] notified and assessed patient. Vitals taken, at baseline. Orders placed for follow up, Attending MD and family notified.” - House Physician Note, dated 04/30/2025 at 5:19 PM, included “I was called to examine the patient who was seen by the RN sitting close to the door. Patient states [Pt. #1] got out of the bed to grab the pack of chips from [Pt. #1’s] locker. Patient is alert and verbalizing but is confused. States [Pt. #1] did not hit his head but sustained a minor avulsion [tear] of the skin to the right elbow, dressing applied. Fall precautions are in place but the bed alarm was not on ... there is no bumps and lumps over the head, no bruises except for the minor avulsion of the skin. Movements of all the joints are normal, able to flex and extend the neck ...” - Post fall safety precautions from 04/30/2025 at 8:12 PM to 05/01/2025 at 2:42 PM did not include any additional fall prevention measures put in place to prevent another fall. Additionally, the record lacked a fall re-assessment to indicate history of falls and the plan of care was not updated to reflect the patient’s risk for falls. Subsequently, Pt. #1 had a second unwitnessed fall on 05/01/2025 at 9:25 AM. 4. The clinical records for patients who had falls (Pt #8 and Pt #9), were reviewed on 12/15/2025. Pt #8 fell on 12/6/2025 and Pt #9 fell on 12/10/2025. There were “Fall Investigation/Huddle Worksheets” completed for both patients following the falls. However, their clinical records lacked a re-screening for fall risk post-fall and lacked an updated fall care plan that included fall interventions/new interventions in place. 5. Seven open clinical records for patients on census on the 3 East Medical/Surgical/Telemetry Unit (Campus B) (Pt #4, Pt #5, and Pts #13-17), were reviewed on 12/15/2025. The most recent fall risk assessments indicated that these patients were all scored as High Fall Risk. 6. On 12/15/2025 at 10:50 AM, an observational tour of 3 East Medical/Surgical/Telemetry Unit (Campus B) was conducted. During the tour, it was noted that 8 patients were on High Fall Risk precautions. In 7 out of the 8 (Pt #4, Pt #5, Pt #13-#17) patient rooms of patients on the High Fall Risk precautions, there were no fall mats in place, and the bed alarms were not activated (patients were in their beds during the tour), as required for high fall risk precautions. 7. On 12/17/2025 at 10:40 AM, an observational tour of 1 East Medical/Surgical/Telemetry Unit (Campus A) was conducted. Three patients (Pt #6, Pt #18, and Pt #19) were on moderate fall risk precautions based on fall risk assessments completed in theier clinical records. During the tour, the patients were observed to be in bed with no fall mats in place, and bed alarms were not activated. 8. On 12/15/2025 at 11:05 AM, an interview was conducted with a RN (E #6). E #6 stated that fall precautions include non-skid socks; bed and chair alarms; low bed; fall mats; and door signage. E #6 stated that fall risk assessments are done on admission, weekly, and post-fall. 9. On 12/17/2025 at 11:30 AM, an interview was conducted with the Chief Nursing Executive (E #2). E #2 stated that a re-assessment should be done following a fall incident. E #2 stated that in addition, the care plan should be updated with new interventions following the fall. E #2 stated that fall mats and bed alarms should be activated if the patient is on Moderate or High Fall Risk precautions.”