Community Rehabilitation Hospital West

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48704 Based on document review, the facility failed to consistently identify and reassess fall risks to ensure a safe setting for 5 of 10 patient (Patient 1, 2, 3, 7, and 8) medical records reviewed. Findings include: 1. Facility policy titled, Patient Rights and Responsibilities, Policy: LDR 270, Revision Date: February 2025, indicated under Patient/Family/Surrogate Rights, 8. The patient has the right to care in a safe setting. 2. Facility policy titled Fall Prevention Plan, Policy PC 200, Revision: December 2024, indicated under Procedure, D. The Fall Scale is used to identify patients at High Fall Risk. The Fall Scale is to be completed: d. Following a fall, and/or e. On regular daily intervals. 3. Review of Incident Report of event dated 12/09/2025 indicated patient 7 was on the top of a 3 step stairway, patient lost their balance, fell backwards landing on back and hitting head on floor. Facility #1 (Acute Rehabilitation Facility) Root Cause Analysis indicated PT1 (Physical Therapy Assistant) admitted letting go of the gait belt, going down the other side of the steps, around the stairs attempting to get to the other side to help break the fall after realizing the patient was going to fall down the stairs. Patient was admitted to Facility #2 with a post scalp hematoma and a T9 (thoracic) fracture with ligament injury. 4. Review of Patient 1’s medical record indicated the following: a. The patient was admitted on 10/17/2025. b. Medical record lacked documentation of the daily fall risk assessment on 10/18/2025, 10/19/2025, and 0/25/2025. c. The patient was discharged on 11/01/2025. 5. Review of Patient 2’s medical record indicated the following: a. The patient was admitted on 10/16/2025. b. Medical record lacked documentation of the daily fall risk assessment on 10/26/2025. c. The patient was discharged on 11/06/2025. 6. Review of Patient 3’s medical record indicated the following: a. The patient was admitted on 11/03/2025. b. Medical record lacked documentation of the daily fall risk assessment on 11/04/2025. c. The patient was discharged on 11/17/2025. 7. Review of Patient 7’s medical record indicated the following: a. The patient was admitted on 11/28/2025. b. Medical record lacked documentation of the daily fall risk assessment on 12/02/2025, 12/03/2025. c. On 12/09/2025, patient had a fall during a physical therapy trial on the stairs. Nursing note indicated provider notified that patient had posterior rib cage pain, and a knot forming on posterior head. Provider ordered patient to be transferred to emergency room for further evaluation. d. Patient was admitted to Facility #2 (Acute Care Facility) for further treatment. 8. Review of Patient 8’s medical record indicated the following: a. The patient was admitted on 12/11/2025. b. Medical record lacked documentation of the daily fall risk assessment on 12/12/2025, 12/13/2025, 12/20/2025, and 12/21/2025 day. c. The patient was discharged on 12/22/2025.”

“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: 48704 Based on document review and interview, nursing failed to document daily fall risk assessments in 5 of 10 (Patient 1, 2, 3, 7, and 8) medical records reviewed. Findings include: 1. Facility policy titled Fall Prevention Plan, Policy PC 200, Revision: December 2024, indicated under Procedure, D. The Fall Scale is used to identify patients at High Fall Risk. The Fall Scale is to be completed: d. Following a fall, and/or e. On regular daily intervals. 2. Review of Patient 1’s medical record indicated the following: a. The patient was admitted on 10/17/2025. b. Medical record lacked documentation of the daily fall risk assessment on 10/18/2025, 10/19/2025, and 0/25/2025. c. The patient was discharged on 11/01/2025. 3. Review of Patient 2’s medical record indicated the following: a. The patient was admitted on 10/16/2025. b. Medical record lacked documentation of the daily fall risk assessment on 10/26/2025. c. The patient was discharged on 11/06/2025. 4. Review of Patient 3’s medical record indicated the following: a. The patient was admitted on 11/03/2025. b. Medical record lacked documentation of the daily fall risk assessment on 11/04/2025. c. The patient was discharged on 11/17/2025. 5. Review of Patient 7’s medical record indicated the following: a. The patient was admitted on 11/28/2025. b. Medical record lacked documentation of the daily fall risk assessment on 12/02/2025, 12/03/2025. Medical record lacked documentation of a fall risk assessment following patient’s fall on 12/09/2025. c. The patient was transferred to an outside facility for further evaluation on 12/09/2025. 6. Review of Patient 8’s medical record indicated the following: a. The patient was admitted on 12/11/2025. b. Medical record lacked documentation of the daily fall risk assessment on 12/12/2025, 12/13/2025, 12/20/2025, and 12/21/2025 day. c. The patient was discharged on 12/22/2025. 7. Interview with A1 (Director of Therapy) and A2 (Director of Quality) on 01/29/2026 at approximately 5:00 p.m. confirmed the above medical records lacked documentation of the daily fall risk assessments.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to ensure that a transfer order was written in 1 of 10 (Patient 7) medical records reviewed. Findings include: 1. Facility policy titled Discharge - Transfer of Patient To Or From Facility, Policy PC 580, Revision Date: August 1, 2023, indicated under Policy, 3. There must be an order from an authorized practitioner to transfer the patient. 2. Review of Patient 7’s medical record indicated the following: a. The patient was admitted on 11/28/2025. b. On 12/09/2025, the patient was transferred to an outside facility for further evaluation, and medical record lacked documentation of a transfer order. 3. Interview with A2 (Director of Quality) on 01/29/2026 at approximately 5:00 p.m. confirmed the patient 7’s medical record lacked a transfer order.”