Pam Health Rehabilitation Hospital of Sugar Land

“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: 37490 Based on observation, interview, and record review, the facility failed to ensure the patient’s right to care in a safe setting by failing to implement appropriate fall prevention interventions in 2 of 3 patients (ID#s 10 and 11). Findings include: Record review of the facility policy titled “Patient Rights and Responsibilities,” last reviewed August 13, 2025, showed the following: PURPOSE The purpose of this policy is to ensure that every PAM patient is aware that his/her basic rights for independence of expression, decision and concern for personal dignity are preserved and to define POLICY It is the policy of PAM Health to respect the individual rights of all patients that come to a hospital for care. Patient rights include the right to make decisions regarding medical care, the right to accept or refuse treatment, and the right to formulate advance directives. Patient responsibilities include those actions on the part of patients that are needed so that healthcare providers can provide appropriate care, make accurate and responsible care decisions, address patients’ needs, and maintain a sound and viable health care hospital. PROCEDURES 6. Patients’ Rights: Patients have the rights to: n) Receive care in a safe setting, free from mental, physical, sexual, or verbal abuse and neglect, exploitation or harassment. The patient has the right to access protective services and advocacy services including notifying government agencies of neglect or abuse. Record review of the facility policy titled “Fall Prevention,” last reviewed March 23, 2026, showed the following: POLICY To identify patients who present a risk for falls and to provide reasonable measures to prevent falls and fall-related injuries. This policy and procedure apply to all patients to whom care is rendered at PAM hospitals. PURPOSE To provide a guide for assessing patients who are at risk for falling and for implementing precautionary measures to reduce the probability that a patient will fall or to reduce the probability the patient will sustain a serious injury in the event of a fall. FALL RISK ASSESSMENT The nursing fall risk assessment and interventions are based on the use of the modified Morse Fall Scale. Patients will be assessed for fall risk factors upon admission, daily, change in clinical status, transfer to a new setting, and post-fall. Low Risk <25 See Universal Fall Prevention Interventions Moderate Risk 25-45 See Moderate Fall Prevention Interventions High Risk >45 See High-Risk Fall Prevention Interventions UNIVERSAL FALL PREVENTION INTERVENTIONS Patients who are scored “low risk” on the modified Morse Fall Scale (score 0-24) will have the following interventions considered by the healthcare team. The healthcare team should tailor the interventions to be patient specific. · Orient patients to surroundings and hospital routines. · Bed in a low position. · Use treaded socks for patients when out of bed. · Personal items, call bell, cane/walker within reach · Room cleared of all unnecessary equipment. · Lock all moveable equipment before transferring the patient. MODERATE FALL PREVENTION INTERVENTIONS Patients who are scored “moderate risk” on the modified Morse Fall Scale (score of 25-45) will have the following interventions considered for implementation by the healthcare team in addition to the Universal Interventions. The healthcare team should tailor the interventions to be patient-specific. Examples of interventions may include: · Assess the patient’s coordination and balance before assisting with transfer and mobility activities. ·Initiate treatment for impaired vision and hearing (provide eyeglasses/hearing aids when available). · Pharmacist will evaluate medication profile for fall risk. · Review medications with the physician. · Place colored, non-skid socks · Place fall risk signs on the door · Offer toileting at breakfast, lunch, and dinner, before bedtime, and with pain medication administration. · Assist and monitor the patient in the bathroom. · Approach the patient towards the unaffected side to maximize participation in care. · Transfer the patient towards the stronger side. · All ambulatory aides within reach/on the functional side · Consider using a non-skid floor mat. · Bed and/or chair alarms, as applicable · Fall alarms, as applicable. · Consider using low beds for patients at risk for falls. · Consider family members staying with the patient. · Increased observation level of patient HIGH-RISK FALL PREVENTION INTERVENTIONS These interventions are designed to be considered for patients with multiple risk factors, who are scored “high risk” on the modified Morse Fall Scale (score of >45) and have fallen. They are designed to reduce the severity of injuries due to falls as well as to prevent falls from reoccurring, supplementing Universal and Moderate Fall Prevention Interventions. The healthcare team should tailor the interventions to be patient specific. · Apply fall risk armband. · Remain with the patient while toileting. · Assist and monitor the patient in the bathroom. · Offer toileting at breakfast, lunch, and dinner, before bedtime, and with pain medication administration. · Review medications for fall risk and adjust as indicated. · Consider using a non-skid floor mat. · Consider using a low bed. · Consider referral to services such as PT/OT, audiology, ophthalmology, and cardiology. · Optimize treatment of underlying medical conditions. · Evaluate and treat pain. Observation on 4/29/2026 at 10:30 AM patient (ID# 10) in the patients room the bed alarm was not on and the patient did not have on non skid socks. Observation on 4/29/2027 at 10:45 AM patient (ID# 11) in the patient’s room the bed was not placed in the lowest position, and the bed alarm was not on. Interview with RN staff (ID# 63) on 4/29/2026 at 11:20 AM confirmed the above findings and that patients were “High” fall risks.”

“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: 46010 Based on record review and interview, the facility failed to ensure that a Registered Nurse performed an assessment of a patient who had an unwitnessed fall, physical exam evidence of trauma and clinical deterioration requiring code blue response in 1 of 17 patients reviewed (Patient ID #3). Findings Included: Review of facility policy titled “Fall Prevention”, last reviewed March 23, 2026, stated “Did patient strike head and/or on anticoagulants or platelet inhibitors? Yes - 1. Complete a thorough nursing assessment. Does the patient have any of the following: Spinal pain or tenderness, Abnormal motor and sensory exam, Unconsciousness.” Record review of facility policy titled “Guidelines for Nursing Care”, last reviewed March 23, 2026, stated “Assessment: Every shift and with significant condition changes. RN must assess once every 24 hours.” Medical record review for Patient ID # 3 revealed on 09/24/25 at 12:03 pm, the patient sustained an unwitnessed fall from a toilet with PEA. Rapid response was called and then Code Blue. Licensed Vocational Nurse Staff ID # 68 documented “I was called by another nurse that patient fell in the bathroom. Code Blue was called. I found the patient on the floor face down with blood oozing from the forehead and multiple skin tears noted on Left Forearm. OT left the bathroom as soon as I arrived. I immediately arouse the patient and she responded. She was awake with a pulse. Code Blue was changed to Rapid Response. But upon transferring the patient from the floor to the wheelchair patient passed out and became unresponsive, lips were gray. CPR was immediately initiated, Code Blue was called and patient was hook on bedside monitor and BVM performed by RT. Initial rhythm was PEA. After over a minute of CPR patient had a pulse and return to NSR. An IV line was started and NS Bolus was administered to L forearm. Patient had good pulse and RT was still providing BVM. After about 12-15 minutes ambulance arrived and resumed care and patient was transferred to Memorial Hermann TMC. I also notified patients daughter of the event after ambulance arrived to resume care. Patient vital signs documented in rapid response and code blue form.” Interview on 4/29/26 at 11:05 am with Quality RN ID # 54 with medical record review. She confirmed that she was unable to locate an assessment from a Registered Nurse, after the Code Blue event and prior to 911 transfer to an acute care hospital for Patient ID #3. She confirmed she would have expected a Registered Nurse to assess the patient due to a change of status per state scope of practice rules. She was asked to clarify the “assessment” for the Guidelines of Nursing Care policy. She confirmed that the nursing assessment, for a patient with a significant condition change, would require a Registered Nurse to assess and document the assessment.”