Kindred Hospital-Tarrant County

“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: 39057 Based on interviews and record reviews, the facility failed to ensure the right to receive care in a safe setting for one (Patient #1) of five patients reviewed for fall risk. Although assessed to be a high risk for falls, Patient #1’s bed alarm had not been activated, and his bed rails were not raised when the patient experienced a fall and hurt his right knee on 05/27/2026. Findings included: Record review of Patient #1’s History and Physical dated 05/07/2026 reflected Patient #1 was a 38-year-old male with a history of malignant hypertension and obesity, admitted to the facility on 05/04/2026 from an emergent decompressive craniectomy with partial lobectomy and hematoma evacuation. Patient had history of acute hypoxic respiratory failure requiring intubation, ventilation. Patient remained vent dependent and underwent a tracheostomy on 04/13/2026. He was currently tolerating trach collar. PEG tube was placed for dysphagia. Record review of Patient #1’s Fall assessment reflected: 05/09/26 06:41: “Fall risk screening: High/low fall risk factors: Complete paralysis or completely immobilized Fall risk level: low.” 05/25/26 11:24: “Fall risk level: high” 05/26/26 0800: “Fall risk level: high” 05/27/26 12:01: “Fall risk screening: High/low fall risk factors: Patient is deemed high fall risk due to a diagnosis that places patient at risk. Fall risk level: high.” 05/27/26 18:52 (after fall): “Fall risk screening: High/low fall risk factors: Patient is deemed high fall risk due to a diagnosis that places patient at risk. Fall risk level: high.” During a telephone interview on 06/26/2026 at 9:40 AM, Personnel A stated they had seen Patient #1 earlier in the day of the fall and the patient was on “fall precaution with a yellow sign on door, yellow socks and armband. Patient had orders for side rails times 3; which meant the two middle railings and one head railing were up.” During a telephone interview on 06/26/2026 at 3:34 PM, Personnel F stated they were in Patient #1’s room with Personnel E and Personnel A to help clean the patient and then provided passive range of motion therapy. Personnel F reported they left the room after providing care and Personnel E was the only one that remained in the patient’s room. Personnel F reported when she arrived to Patient #1’s room after the fall, the (right) side rail was down. During a telephone interview on 06/30/2026 at 11:46 AM, Personnel E stated they were in Patient #1’s room prior to the fall on 05/27/2026 to clean the patient and adjust the patient on the bed. Personnel E stated that Patient #1 was “high fall risk due to history of stroke and intermittent confusion.” Personnel E stated Patient #1 fell less than an hour later as noticed during routine rounding and “no bed alarms [were] going off ... bed alarm was not activated.” Personnel E reported the patient was on the floor on the right side of the bed when they entered the room. Once assisted back to bed, Patient #1 indicated right knee pain. When asked what precautions should have been in place for high-risk patients. Personnel E stated, “side rails up time three, call light within reach, and frequent rounding.” During a phone call dated 06/30/2026 at 01:06 PM, Personnel E confirmed that Patient #1’s “right side bed rails [were] down ... there was an issue with the right railing not locking...the patient might have put some weight on the railing, and it came down.” Record review of the facility’s Policy and Procedure titled, Procedure-Falls Prevention, dated 05/2025 reflected the policy to “ ... 1. At the time a fall risk screen is completed, appropriate fall intervention precautions are initiated. 2. ... The fall risk score is discussed as part of the Interdisciplinary Care Transitions (ICT) conference to determine and implement appropriate patient specific interventions to prevent falls...” The procedure recommended: 1. Initial patient evaluation: C: A score of 6-13 total points - Moderate Fall Risk ... 7) implement bed and/or chair alarm ... D. A score of >13 total points = High Fall Risk include: 1) Low fall and moderate Fall risk interventions ... 3) Use side rail extenders for specialty mattresses per guidelines, 4) Move patient to room with best visual access to nursing stations ... 6) protective devices such as mats on the floor, etc ...”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 39057 Based on interviews and record reviews, the facility failed to ensure the nursing staff developed, and kept current a nursing care plan for each patient that reflected the nursing care to be provided to meet the patient’s needs for 1 (Patient #1) of five patients reviewed for fall risk. Patient #1 had been admitted from an acute care hospital on 05/04/2026 with medical history of surgical procedures that included an craniectomy and partial lobectomy and remained ventilator dependent with a tracheostomy. Although nursing staff screened the patient to be a high fall risk due to his medical condition, nursing failed to identify the patient’s safety need in the nursing care plan for more than three weeks until Patient #1 was found on the floor on 05/27/2026 and complained of knee pain. Findings included: Record review of Patient #1’s History and Physical dated 05/07/2026 reflected Patient #1 was a 38-year-old male with a history of malignant hypertension and obesity, admitted to the facility on 05/04/2026 from an emergent decompressive craniectomy with partial lobectomy and hematoma evacuation. Patient had history of acute hypoxic respiratory failure requiring intubation, ventilation. Patient remained vent dependent and underwent a tracheostomy on 04/13/2026. He was currently tolerating trach collar. PEG tube was placed for dysphagia. Record review of Patient #1’s Fall assessment by several nursing staff reflected: 05/09/26 06:41: “Fall risk screening: High/low fall risk factors: Complete paralysis or completely immobilized Fall risk level: low” 05/25/26 11:24: “Fall risk level: high” 05/26/26 0800: “Fall risk level: high” 05/27/26 12:01: “Fall risk screening: High/low fall risk factors: Patient is deemed high fall risk due to a diagnosis that places patient at risk. Fall risk level: high.” During a telephone interview on 06/30/2026 at 11:46 AM, Personnel E stated they were in Patient #1’s on 05/27/2026 to clean the patient and adjust his position on the bed. Personnel E stated that Patient #1 was “high fall risk due to history of stroke and intermittent confusion.” Personnel E staff found Patient #1 on the floor during rounding less than an hour later. Patient #1 complained of knee pain. When asked what precautions should have been in place for high-risk patients. Personnel E stated, “side rails up time three, call light within reach, and frequent rounding.” Review of Patient #1’s Care Plan on .... did not reflect the patient’s high fall risk with prevention interventions prior to the unwitnessed fall on 05/27/2026. On 05/27/2026 at 7:42 PM, Patient #1’s care plan was updated with “Pt Care Dx. Risk for falls: Related to: history of previous falls.” At 7:44 PM entry was made reflecting, “High Fall Risk: Verify placement of bed/chair alarm: Start 05/27/26 22:00, q shift ...” Personnel #G stated during an interview on 06/30/2026 at 4:00 PM that they did not realize there was no fall risk care plan for Patient #1 prior to the fall on 05/27/2026. Record review of the facility’s policy and procedure titled, “Procedure-Falls Prevention”, dated 05/2025, reflected the following: GUIDELINES: 1. At the time a fall risk screen is completed, appropriate fall intervention precautions are initiated ... PROCEDURE: ... 2. Ongoing patient evaluation: a. Patients identified as being at risk for falls will have an interdisciplinary care plan initiated by the registered nurse under the heading “risk for falls ...”

“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: 28637 Based on interviews and record reviews, the facility failed to ensure the right to receive care in a safe setting for one (Patient #1) of five patients reviewed for high fall risk, 1. Patient #1 sustained an unwitnessed fall and was found on the floor of her room, in front of her wheelchair, following a Physical Therapy session on 05/01/2026. A Restorative Nursing Assistant assisted Patient #1 to bed and did not notify her nurse for at least 30 minutes so that a post-fall assessment could be completed. 2. Although assessed to be a high risk for falls, Patient #1 was not wearing a fall risk bracelet, no fall signage was used in her room the day she fell (05/01/2026), and no bed alarm was activated for the patient after her fall. Findings included: 1. Record review of Patient #1’s History and Physical dated 04/23/2026 reflected Patient #1 was a 65-year-old female with a history of end-stage renal disease on dialysis, strokes, seizure disorder, and high blood pressure admitted to the facility on 04/23/2026 from an acute care hospital stay following a ground level fall resulting in a sub-dural hematoma [blood collection between the brain and skull]. She had seizures, required ventilator care and feeding through a tube. Record review of Patient #1’s Fall Risk Screening dated 04/23/2026 reflected, “Fall risk screening: ... Patient is deemed high fall risk due to a diagnosis that places patient at risk Fall risk level: high”. No care interventions were documented as necessary to keep the patient safe. Record review of Patient #1’s Fall Risk Screening dated 04/24/2026 reflected, “ ... Total fall risk score: 18 (High Fall Risk)” During an interview on 05/05/2026 at 1:57 PM, Personnel E stated he and Personnel F worked with Patient #1 for ambulation on 05/01/2026 and then placed her in her wheelchair with her call light in reach. Personnel E stated he was told approximately 15 minutes later by Personnel F that he had found Patient #1 on the floor and had placed her in her bed. He stated he did not learn until later that Personnel E had not informed Patient #1’s nurse that she had fallen so he immediately reported the matter to her nurse and checked on the patient. Personnel E stated he had observed Patient #1 was not wearing a fall alert bracelet. During an interview on 05/05/2026 at 2:33 PM, Personnel F stated he had been assisting Personnel E during therapy rounds on 05/01/2026 and had assisted with placing Patient #1 into her wheelchair. He stated, about 15 minutes later, he walked by her room and checked on her and found her on the floor in front of her wheelchair, sitting on her bottom. He stated she denied any pain or injuries, so he assisted her back to her wheelchair then into her bed. Personnel F stated he left and continued assisting Personnel E with rounds and had informed him about Patient #1’s fall approximately 30 minutes after placing her in her bed. He stated he did not know he needed to report the fall to Patient #1’s nurse until Personnel E informed him. When surveyor asked about training how and when to report patient fall incidents to nursing, Personnel F stated he could not recall specifically what he had been taught 2. Record review of Patient #1’s Fall Risk Screening dated 05/02/2026 reflected, “Fall risk screening: High/low fall risk factors: Patient is deemed high fall risk due to a diagnosis that places patient at risk. Fall risk level: high”. During a telephone interview on 05/06/2026 at 9:59 AM, Personnel J stated she was Patient #1’s nurse on 05/01/2026. She stated when Personnel E and Personnel F had informed her about Patient #1 being found on the floor, she went immediately to assess the patient. She stated Patient #1 denied complaints of pain and had no injuries identified. Personnel J stated she could not recall whether Patient #1 had been wearing a fall alert bracelet earlier in the day and she was not wearing one during her assessment. She stated she did not typically look for one as part of fall precautions. Personnel J stated Patient #1’s bed alarm was not activated when she had assessed her after the fall, and she did not recall activating it. She stated she saw that the patient’s bed was low and locked, and her call light and personal items were in reach. Personnel J stated she did not use the bed alarm for Patient #1 because she had not received reports of her attempting to climb out of bed. She stated she placed a fall alert bracelet on Patient #1 after her family complained she was not wearing one. During an interview on 05/06/2026 at 10:48 AM, Personnel K stated when a patient was at risk for falls, an armband should have been placed indicating fall risk and staff should have marked it on the whiteboard inside the patient’s room. She stated she was on duty and had been informed about Patient #1’s fall from Personnel E. She stated she spoke with Personnel J who told her she had just assessed the patient. Personnel K stated she went and assessed her as well and noted Patient #1 did not have a fall alert bracelet on and there was no signage in the room indicating she was high fall risk. She stated her bed was in a low position and her bed alarm was on. [The surveyor received conflicting information regarding the timing of Patient #1’s bed alarm activation.] Personnel K stated she initiated the post-fall protocol and assisted with making notifications. Record review of the facility’s Policy and Procedure titled, Procedure-Falls Prevention, dated 05/2025 reflected the policy to “ ... 1. At the time a fall risk screen is completed, appropriate fall intervention precautions are initiated. 2. ... The fall risk score is discussed as part of the Interdisciplinary Care Transitions (ICT) conference to determine and implement appropriate patient specific interventions to prevent falls...” The procedure recommended .... the interventions for patients assessed with a risk assessment score of 13 and higher included, “ ... 2) assist bedside sitting bed ...7) Implement bed and/or chair alarms ...”.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 28637 Based on interviews and record reviews, the facility failed to ensure the nursing staff developed, and kept current a nursing care plan for each patient that reflected the nursing care to be provided to meet the patient’s needs for 1 (Patient #1) of five patients reviewed for fall risk in that, Patient #1 had been admitted on 04/23/2026 from an acute care hospital where she had been treated for brain bleeding after she experienced a fall. The patient had seizures and required ventilator care. Although identified as a high fall risk on admission and additional nursing screenings, the patient’s potential for falls was not included in her care plan, and no individualized nursing interventions were identified to meet the patient’s safety needs. One week into her hospitalization, Patient #1 experienced a fall in her room. There was no evidence that Patient #1’s care plan was updated or expanded after the incident according to hospital policy. Findings included: Record review of Patient #1’s History and Physical dated 04/23/2026 reflected Patient #1 was a 65-year-old female with a history of end-stage renal disease on dialysis, strokes, seizure disorder, and high blood pressure admitted to the facility on 04/23/2026 from an acute care hospital stay following a ground level fall resulting in a sub-dural hematoma [blood collection between the brain and skull]. She had seizures, required ventilator care and feeding through a tube. Record review of Patient #1’s Fall Risk Screening dated 04/23/2026 reflected Patient #1 was assessed to a “high fall risk due to a diagnosis that places [the] Patient at risk.” The document did not reflect care interventions for potential falls. Record review of Patient #1’s Fall Risk Screening dated 04/24/2026 reflected, “ ... Total fall risk score: 18 (High Fall Risk).” There was no evidence of documented care intervention for falls. During a telephone interview on 05/06/2026 at 9:59 AM, Personnel J stated she was Patient #1’s nurse on 05/01/2026, the day she fell. Personnel J went to assess the patient. She stated Patient #1 denied complaints of pain and had no injuries identified. She stated the physician and family were notified with the assistance of Personnel E and Personnel K. Personnel J stated she could not recall whether Patient #1 had been wearing a fall alert bracelet earlier in the day and she was not wearing one during her assessment. She stated she did not typically look for one as part of fall precautions. Personnel J stated Patient #1’s bed alarm was not activated when she had assessed her after the fall, and she did not recall activating it. She stated she saw that the patient’s bed was low and locked, and her call light and personal items were in reach. Personnel J stated she did not use the bed alarm for Patient #1 because she had not received reports of her attempting to climb out of bed. She stated she placed a fall alert bracelet on Patient #1 after her family complained she was not wearing one. During an interview on 05/06/2026 at 10:48 AM, Personnel K stated when a patient was at risk for falls, an armband should have been placed indicating fall risk and staff should have marked it on the whiteboard inside the patient’s room. She stated she was on duty and had been informed about Patient #1’s fall from Personnel E. She stated she spoke with Personnel J who stated she had just assessed the patient. Personnel K stated she went and assessed her as well and noted Patient #1 did not have a fall alert bracelet on and there was no signage in the room indicating she was high fall risk. She stated her bed was in a low position and her bed alarm was on. Personnel K stated she initiated the post-fall protocol and assisted with making notifications. During an interview and record review on 05/06/2026 at 12:45 PM, Patient #1’s Plan of Care, dated 04/23/2026 through 05/06/2026, located within her Electronic Medical Record (EMR) was reviewed with Personnel A. No entries related to Patient #1’s fall risk was located in her Plan of Care, and no specific interventions were included with her daily fall risk assessments indicating her risk level was high. Personnel A stated she did not know why the information was not included in her record. During an interview on 05/06/2026 at 3:06 PM, Personnel B stated he was not aware the patient Care Plans had not been individualized to include her fall risk and specific fall precautions selected for patients. Record review of the facility’s policy and procedure titled, “Procedure-Falls Prevention”, dated 05/2025, reflected the following: “GUIDELINES: 1. At the time a fall risk screen is completed, appropriate fall intervention precautions are initiated ... PROCEDURE: ...Patients identified as being at risk for falls will have an interdisciplinary care plan initiated by the registered nurse under the heading ‘risk for falls.’ Patient/family education related to the patient’s specific risk(s) for falls will be reinforced by the Interdisciplinary Team and documented ... Interdisciplinary interventions will be added to the care plan as each discipline identifies specific needs ...”.”