Milwaukee Rehabilitation Hospital at Greenfield

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 52276 Based on record review and interview, the facility failed to thoroughly document investigations and resolutions regarding patient complaints and grievances with allegations of potential abuse in 2 of 4 caregiver misconduct allegations reviewed (Patient #1 and #13). Findings include: A review facility’s policy titled, “Adverse Event Communication Escalation” last approved 09/2025, “4. Additional Collaboration and Investigation...b. Once the event is resolved, the Nobis leader (2nd contact) will send a final notification email alerting those on the distribution list that the event is resolved...c. If the event is not resolved within 3 hours of the event, a final notification email will be sent by the (system) executive backlogging end of escalation or what the ongoing plan will be.” A review of the facility’s policy titled, “Protecting Patients from Abuse and Neglect” last approved 01/2026 revealed, “...A member of the Hospital’s leadership team will contact Corporate HR and/or Corporate Quality via phone call and the escalation email and investigation will be conducted... 3. Any staff member involved in an abuse and neglect allegation will be relieved of duty immediately and leave the premises... 4. The local Police department will be called during the shift and notified of the incident. 5. The Complaint and Grievance policy will be followed for all allegations of abuse and/or neglect and the Complaint and Grievance form will be completed to include the section on abuse/neglect allegations. The completed form will be given to the Director of Quality Management and the Human Resources Department...7. If allegations are substantiated, appropriate state agencies will be contacted. C. Investigation and Reporting of Possible Abuse and Neglect 1. Any potential incident of abuse or neglect will be investigated by the organization and reported to the Governing Board and the appropriate State and Federal authorities.” Patient #1 was admitted to the facility on 5/22/2026 for ongoing rehabilitation following a hip fracture. A review of the “Patient Grievance and Complaint Form” revealed on 05/24/2026 Patient #1 alleged Certified Nursing Assistant (CNA) C was aggressive during cares causing pain in the left hip and leg. The facility conducted an investigation. There is no evidence of a completed investigation form showing resolution filled out by leadership and given to the Director of Quality Management and Human Resources. There was no evidence a Misconduct Report was submitted to DQA. Patient #13 was admitted to the facility on 9/12/2025-9/26/2025 for ongoing rehabilitation following a spinal cord compression. A review of the “Patient Grievance and Complaint Form” revealed on 09/19/2025 Patient #13 alleged Registered Nurse (RN) V was rude and didn’t change his depends. The facility conducted an investigation. There is no evidence of a completed investigation form showing resolution filled out by leadership and given to the Director of Quality Management and Human Resources. There was no evidence a Misconduct Report was submitted to DQA. During an interview on 06/30/2026 at 10:39 A.M. when asked to see the documentation the case was unsubstantiated CNO P stated, “sadly there is no evidence of documentation that I have or the regional office has to confirm that this was unsubstantiated.””

“CONTENT OF RECORD: STANDING ORDERS CFR(s): 482.24(c)(3) (3) Hospitals may use pre-printed and electronic standing orders, order sets, and protocols for patient orders only if the hospital: (i) Establishes that such orders and protocols have been reviewed and approved by the medical staff and the hospital’s nursing and pharmacy leadership; (ii) Demonstrates that such orders and protocols are consistent with nationally recognized and evidence-based guidelines; (iii) Ensures that the periodic and regular review of such orders and protocols is conducted by the medical staff and the hospital’s nursing and pharmacy leadership to determine the continuing usefulness and safety of the orders and protocols; and (iv) Ensures that such orders and protocols are dated, timed, and authenticated promptly in the patient’s medical record by the ordering practitioner or another practitioner 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: 52276 Based on interview and record review, the facility failed to ensure a physician’s order was placed prior to patients leaving the facility for 4 of 7 patients (Patients #1, 4, 6, 11) with outside appointments in a total sample of 11 medical records reviewed. Findings include: Review of the facility’s policy “Outside Services Transportation,” #19557400 dated 03/2026 revealed, “...When the physician has determined that it is clinically necessary for an inpatient to have a ...physician office visit, transportation appropriate for the patients’ medical condition will be arranged ... A. Transportation- The physician directs the mode of transportation ...physician shall be responsible for writing an order for the outside service required.” Review of Patient #1’s medical record revealed Pt. #1 was transported to an outside facility for a medical appointment on 06/04/2026 with no documentation of time Pt. #1 left the facility or returned. There was no physician’s order for the outside appointment or mode of transportation. Review of Patient #4’s medical record revealed Pt. #4 was transported non emergently to a higher level of care on 6/29/2026 with no documentation of time Pt. #4 left the facility. There was no physician’s order for Pt. #4 to be transferred. Review of Patient #6’s medical record revealed Pt. #6 was transported to an outside facility for a medical appointment on 06/29/2026 with no documentation of time Pt. #6 left the facility or returned. There was no physician’s order for the outside appointment or mode of transportation. Review of Patient #11’s medical record revealed Pt. #11 was transported to an outside facility for a medical appointment on 06/29/2026 with no documentation of time Pt. #11 left the facility or returned. There was no physician’s order for the outside appointment or mode of transportation. During an interview on 06/30/2026 at 10:39 A.M. MD O stated, “a MD order is needed for all transfer outs for appointments and for transfers for higher level of care.” During an interview on 06/30/2026 at 12:20 P.M. CNO L stated, “there should be an order to transfer the patient to an appointment or transfer the patient to a higher level of care.” When asked who is responsible for ensuring the order is placed before the patient transfers out, CNO L stated, “the nurse.””

“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: 29963 Based on record review and interview the facility staff failed to complete documentation of a nursing physical assessment following a patient fall in 3 of 14 falls (Patient # 5, 6, 9); failed to complete post fall documentation for 2 of 14 falls (Patient #5 (for 2 falls)); failed to evaluate and revise the care plan with appropriate interventions and goals to reflect patient care needs in 4 of 10 patient falls (Patient #5, 6, 9, 11); failed to ensure established fall interventions were utilized correctly by staff for 2 of 10 Patients (Patient #1 and 5) in a total sample of 10 medical records reviewed; and failed to ensure that contract agency staff are trained and demonstrate competency in patient transfer and transfer equipment for 2 of 2 agency Certified Nursing Assistants (CNA) (CNA R, CNA S) in a total of 10 personnel files reviewed. Findings include: Facility staff failed to document nursing physical assessments and failed to complete post fall documentation after patient falls. See tag A-0395 Facility staff failed to follow facility policy to update the Plan of Care following a patient fall and failed to ensure falls interventions were utilized per recommendations. See tag A-0396 Facility staff failed to ensure contract/agency staff are trained and demonstrate competency in patient transfers and transfer equipment. See tag A-0397.”

“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: 29963 Based on record review and interview, the staff failed to document the nursing physical assessment following a patient fall after 3 of 14 patient falls involving Patient (#5, 6, 9); and failed to complete a post fall documentation for 2 of 14 falls (Patient #5 for 2 falls) in a total sample of 10 medical records reviewed. Findings include: A review of policy titled, “Patient Falls Program” Version 2 dated 09/05/2023 revealed, “Documentation in the Medical Record: Patients assessed/reassessed as a risk for fall shall have said assessment/reassessment documented in their medical record. The medical record should also reflect documentation of interventions deployed to prevent a fall. If a fall occurs; Assess the patient for injury prior to moving. Notify physician and notify family member. Document the physical assessment and events in the chart and complete the post-fall assessment in the EMR. Conduct post fall assessment or consider debrief with team members to determine immediate/root cause of the fall within 15 minutes of the fall and plan further interventions. An incident report should be completed and turned in to the quality department.” Nursing physical assessments of the patient following a fall not completed: A review of Patient #5’s medical record revealed an admission date of 03/20/2024 following a CVA (Cerebral Vascular Accident). Patient #5 remains a current patient at the facility. A review of facility falls log for month of March, April, and May 2024 revealed Patient #5 had 5 falls since admission (03/25/2024, 04/07/2024, 04/21/2024, 04/23/2024, and 05/01/2024). A review of the “Incident Report” for Patient #5 revealed “Incident Date: 04/23/2024 Incident Time: 1:00 AM Report Date: 04/24/2024” revealed, “On 04/24/2024 day shift, the patient reported to therapy that she had a fall the night before. DQM (Director of Quality Management) followed up with the patient and she reported a girl came in to take her to the bathroom. The girl placed the wheelchair in front of the patient, and not at the side as they usually do. Additionally, the patient stated the girl did not use a gait belt. The patient reports the girl was trying to transfer patient and the patient slid to the floor and landed on her buttocks. The patient denies any injury or pain. The patient reports “[RN V] came in to help the girl.” They put the patient into bed.” A review of Patient #5’s medical record was completed. There was no documentation of Patient #5 having a fall on 04/23/2024, or a physical assessment following the fall in the medical record. A review of Patient #6’s medical record revealed an admission date of 04/19/2024 following weakness. Patient #6 remains a current patient at the facility. A review of the facility falls log for month of March, April, and May 2024 revealed Patient #6 had 2 falls since admission (05/02/2024 and 05/04/2024). A review of the “Incident Report” for Patient #6 revealed “Incident Date: 05/02/2024 Incident Time: 8:15 AM Report Date: 05/02/2024” revealed, “Pt found sitting on the floor in front of the recliner. Pt. complains of back and knee pain. Pt. states she was trying to get up and did not push call light to notify staff. Chair alarm in place and grip socks on prior to fall. Staff notified and asked to anticipate patient’s needs where possible to help prevent additional falls. Staff agrees.” A review of Patient #6’s medical record was completed. There was no documentation of Patient #6 having a fall on 05/02/2024, or a physical assessment following the fall in the medical record. A review of Patient #9’s medical record revealed an admission date of 03/07/2024 following a CVA. Patient #9 was discharged from the facility on 04/06/2024. A review of the facility falls log for month of March, April, and May 2024 revealed Patient #9 had 2 falls since admission (03/09/2024 and 04/05/2024). A review of the “Incident Report” for Patient #9 revealed “Incident Date: 04/05/2024 Incident Time: 3:15 PM Report Date: 04/05/2024” revealed, “Patient’s chair alarm sounded- CNA (Certified Nursing Assistant), CNO (Chief Nursing Officer), & nursing supervisor entered pt’s room to find pt. kneeling on floor in front of wheelchair; pt reported needing to have a bowel movement- had not utilized call light.” A review of Patient #9’s medical record was completed. There was no documentation of Patient #9 having a fall on 04/05/2024, or a physical assessment following the fall in the medical record. During an interview on 05/06/2024 at 2:00 PM the medical record review findings were discussed with and confirmed by DQM (Director of Quality Management) C who stated, “When a patient has a fall the staff are expected to document the fall and the physical assessment in the medical record.” Nursing post fall review and root cause analysis not completed: A review of Patient #5’s medical record revealed an admission date of 03/20/2024 following a CVA (Cerebral Vascular Accident). Patient #5 remains a current patient at the facility. A review of facility falls log for month of March, April, and May 2024 revealed Patient #5 had 5 falls since admission (03/25/2024, 04/07/2024, 04/21/2024, 04/23/2024, and 05/01/2024). A review of the “Incident Report” for Patient #5 revealed “Incident Date: 04/21/2024 Incident Time: 4:15 AM Report Date: 04/21/2024” revealed, “Pt was brought to the toilet by CNA, Pt did not call for assistance and tried to wipe herself. Pt. lost balance and fell off toilet. Pt. denies hitting head, pain, or injury...” A review of Patient #5’s medical record was completed. There was no documentation of the post fall review for Patient #5’s fall on 04/21/2024. A review of the “Incident Report” for Patient #5 revealed “Incident Date: 04/23/2024 Incident Time: 1:00 AM Report Date: 04/24/2024” revealed, “On 04/24/2024 day shift, the patient reported to therapy that she had a fall the night before. DQM followed up with the patient and she reported a girl came in to take her to the bathroom. The girl placed the wheelchair in front of the patient, and not at the side as they usually do. Additionally, the patient stated the girl did not use a gait belt. The patient reports the girl was trying to transfer patient and the patient slid to the floor and landed on her buttocks. The patient denies any injury or pain. The patient reports “[RN V] came in to help the girl.” They put the patient into bed.” A review of Patient #5’s medical record was completed. There was no documentation of the post fall review for Patient #5’s fall on 04/23/2024. During an interview on 05/06/2024 at 2:00 PM the medical record review findings were discussed with and confirmed by DQM C who stated, “When a patient has a fall the staff are expected to document the post fall assessment in the medical record.””

“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: 29963 Based on record review and interview the facility staff failed to evaluate and revise the care plan with appropriate interventions and goals to reflect patient care needs in 4 of 10 medical records reviewed (Patient #5, 6, 9, 11) and staff failed to ensure established fall interventions were utilized correctly by staff for 2 of 10 Patients (Patient #1, 5) in a total sample of 10 patient records reviewed. Findings include: A review of form titled, “Post Fall Huddle Form” dated 09/23/2023 revealed, “Patient Falls Checklist: ...Update Care Plan”. A review of policy titled, “Patient Falls” dated 09/05/2023 revealed, “To identify patients at risk of falling so that appropriate interventions can be implemented... The medical record should also reflect documentation of interventions deployed to prevent falls.” Examples of care plans not being updated: A review of Patient #5’s medical record revealed an admission date of 03/20/2024 following a CVA (Cerebral Vascular Accident). Patient #5 remains a current patient at the facility. A review of facility falls log for month of March, April, and May 2024 revealed Patient #5 had 5 falls since admission (03/25/2024, 04/07/2024, 04/21/2024, 04/23/2024, and 05/01/2024). A review of the “Incident Report” for Patient #5 revealed “Incident Date: 04/21/2024 Incident Time: 4:15 AM Report Date: 04/21/2024” revealed, “Pt was brought to the toilet by CNA, Pt did not call for assistance and tried to wipe herself. Pt. lost balance and fell off toilet. Pt. denies hitting head, pain, or injury...” A review of Patient #5’s medical record was completed. There was no documentation of Patient #5’s care plan being updated after the 04/21/2024 fall. No new fall interventions were added to the care plan. A review of the “Incident Report” for Patient #5 revealed “Incident Date: 04/23/2024 Incident Time: 1:00 AM Report Date: 04/24/2024” revealed, “On 04/24/2024 day shift, the patient reported to therapy that she had a fall the night before. DQM followed up with the patient and she reported a girl came in to take her to the bathroom. The girl placed the wheelchair in front of the patient, and not at the side as they usually do. Additionally, the patient stated the girl did not use a gait belt. The patient reports the girl was trying to transfer patient and the patient slid to the floor and landed on her buttocks. The patient denies any injury or pain. The patient reports “[RN V] came in to help the girl.” They put the patient into bed.” A review of Patient #5’s medical record was completed. There was no documentation of Patient #5’s care plan being updated after the 04/23/3034 fall. No new fall interventions were added to the care plan. Patient #5 had another fall on 05/01/2024. A review of Patient #6’s medical record revealed an admission date of 04/19/2024 following weakness. Patient #6 remains a current patient at the facility. A review of the facility falls log for month of March, April, and May 2024 revealed Patient #6 had 2 falls since admission (05/02/2024 and 05/04/2024). A review of the “Incident Report” for Patient #6 revealed “Incident Date: 05/04/2024 Incident Time: 7:00 AM Report Date: 05/04/2024” revealed, “Pt was trying to self-transfer out of recliner and slid out instead onto her bottom.” A review of Patient #6’s medical record was completed. There was no documentation of Patient #6’s care plan being updated after the 05/04/2024 fall. No new fall interventions were added to the care plan. A review of Patient #9’s medical record revealed an admission date of 03/07/2024 following a CVA. Patient #9 was discharged from the facility on 04/06/2024. A review of the facility falls log for month of March, April, and May 2024 revealed Patient #9 had 2 falls since admission (03/09/2024 and 04/05/2024). A review of the “Incident Report” for Patient #9 revealed “Incident Date: 04/05/2024 Incident Time: 3:15 PM Report Date: 04/05/2024” revealed, “Patient’s chair alarm sounded- CNA (Certified Nursing Assistant), CNO (Chief Nursing Officer), & nursing supervisor entered pt’s room to find pt. kneeling on floor in front of wheelchair; pt reported needing to have a bowel movement- had not utilized call light.” A review of Patient #9’s medical record was completed. There was no documentation of Patient #9’s care plan being updated after the 04/05/2024 fall. No new fall interventions were added to the care plan. A review of Patient #11’s medical record revealed an admission date of 04/26/2024 following a CVA. Patient #11 is a current patient at the facility. A review of the facility falls log for month of March, April, and May 2024 revealed Patient #11 had 1 fall since admission (05/05/2024). A review of the “Incident Report” for Patient #11 revealed “Incident Date: 05/05/2024 Incident Time: 10:20 AM Report Date: 05/05/2024” revealed, “Pt was sliding out of chair. CNA assisted safely to ground.” A review of Patient #11’s medical record was completed. There was no documentation of Patient #11’s care plan being updated after the 05/05/2024 fall. No new fall interventions were added to the care plan. During an interview on 05/06/2024 at 2:31 PM the medical record review findings were discussed with and confirmed by DQM (Director of Quality Management) C who stated, “When a patient has a fall the staff are expected to update the plan of care after each fall.” Examples of fall interventions not being followed: A review of Patient #1’s medical record revealed an admission date of 03/01/2024 with a diagnosis of CVA with hemiplegia (paralysis of weakness on one side of the body including arms, legs, and sometimes face). A review of Patient #1’s “RN Nursing Shift Assessment” dated 03/06/2024 at 1:04 PM written by RN X revealed, “Fall Precautions... bed alarms and Chair alarms.” A review of the incident report involving Patient #1’s fall on 03/07/2024 at 7:23 AM revealed, “Patient found on the floor in room, pt reported he was attempting to take himself to the other side of his bed in his wheelchair when he fell out of his chair, chair alarm was on the chair but hadn’t been turned on per CNA (education provided)...” A review of Patient #5’s medical record revealed an admission date of 03/20/2024 with a diagnosis of CVA with hemiplegia. A review of Patient #5’s care plan dated 03/20/2024 revealed, “Problem: Risk for falls related to cardiovascular abnormalities... Hx (history) of falls with the past 30 days as evidenced by weakness to left side, recent fall... Interventions: ... 5. Assist with all mobility and toileting.” A review of the incident report involving Patient #5’s fall on 04/21/2024 at 4:15 AM revealed, “Pt was brought to toilet by CNA, Pt did not ask for assistance and tried to wipe herself. Pt. lost balance and fell off toilet. Pt. denies hitting head, pain or injury.” Documentation by DQM C on 04/21/2024 at 3:29 PM revealed, “Follow up/Resolution: Per incident report, the patient’s whiteboard reflected not to leave the patient unattended in the bathroom as she has a history of falls. CNA left patient unattended in the bathroom, and patient sustained a fall.” During an interview with DON D on 05/08/2024 at 8:25 AM, DON D stated, “The staff are expected to put new interventions in place following every patient fall. It is also the expectations that staff make sure all the fall prevention interventions are being utilized and followed.””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 29963 Based on record review and interview, the facility staff failed to ensure agency staff are educated and demonstrate knowledge of safe patient handling and movement for 2 of 2 Agency CNA (Certified Nursing Assistant) (Agency CNA R and CNA S) in a total universe of 10 personnel files reviewed. Findings include: A review of policy titled, “Safe Patient Handling and Movement” dated 02/20/2023 revealed, “Staff will be educated in the techniques of safe patient handling and movements and the risk of injury. Devices will be provided by the hospital to decrease the risk to employees, and patients: Hoyer lift, slider boards, gait belts, and others ... Procedure: A. Staff Responsibilities 1. Unit/Nurse Manager and Supervisors are responsible for: a. Ensuring that all staff affected by the policy complete initial and annual training on patient-handling equipment, ambulatory aids, and safe patient handling ... 3. Unlicensed caregivers are responsible for: a. Being knowledgeable of the procedures to follow when transferring patients. b. Using proper techniques, patients handling equipment and ambulatory aids during performance of high-risk patient handling tasks.” A review of form titled, “Job Description” for Agency CNAs dated and signed by CNA R on 09/07/2023 and CNA S on 07/14/2022 revealed, “Job Title: Agency Certified Nursing Assistant, Position Summary: Assists professional nursing personnel in providing patient care in assigned area. Assist patient with activities of daily living, provides for personal care, emotional support and performs more complex clinical skills under the direction of professional nursing personnel.” A review of form titled, “Agency Competency Assessment- CNA” for CNA R revealed a list of “Departmental-Mandated Competencies”, the form did not include any competencies related to the use of patient handling equipment or transfer aids. A review of an “Incident Report” for Patient #1 on 03/06/2024 at 12:25 PM revealed, “[R] the CNA was in the room with the patient [#1], his/her daughter and [spouse]. S/he called for help and [K] RN and [X] RN responded. The patient was on the sara stedy and his/her leg had moved. We moved the sara stedy to the bed and put the patient in a sitting position on the bed. We repositioned his/her legs and got him/her back on the sara stedy and in the shower chair in the bathroom. When seated in the bathroom chair the patient vomited a small amount. [X] RN noticed patients left arm had a skin tear...” During an interview with Director of Nursing D on 05/08/2024 at 8:25 AM, Director of Nursing D stated hospital staff are trained upon hire and then annually on safe patient handling including use of equipment and transfer aids. Director of Nursing D stated that Agency staff complete a competency the first day they work at the hospital, but use of equipment and transfer aids are not included in the competency. Director of Nursing D stated, “As far as agency staff, I would hope they are more experienced and know how to use equipment safely.””

“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: 29963 Based on record review and interview, the facility staff failed to develop and implement appropriate policies and procedures to ensure the safety of patients determined to require continuous 1 to 1 observation in 2 of 3 (Patients #1 and #9) patients with 1:1 observation needs in a total sample of 10 patient medical records reviewed. Findings include: Review of policy titled, “Patient Falls Program” Version 2 dated 09/05/2023 revealed, “Purpose: To identify patients at risk of falls so that appropriate interventions can be implemented ... Each patient shall be assessed to determine the need for patient-specific assessments and reassessments ... Patients assessed/reassessed as a risk for fall shall have said assessment/reassessment documented in the medical record. The medical record should also reflect documentation of interventions deployed to prevent falls.” A review of facility guidelines titled, “One to One Sitter Justification Guidelines” undated revealed, “Any care team member can request a sitter for a patient. The Sitter Request Evaluation Form must be filled out by the requester and turned in to the CNO (Chief Nursing Officer), DQM (Director of Quality Management), or CTO (Chief Therapy Officer) (or designee if all 3 are unavailable) ...If the evaluation warrants the sitter need, the designated approver will notify the requester as soon as possible. If a sitter is needed prior to approval, the supervisor should be notified immediately in order to provide staff who are able to be a sitter during the approval time. An order for a sitter must be placed on the patient chart ... Plan of care should address the need for a sitter and the plan for addressing or discontinuing the sitter prior to any level discharge. The team should decide the safety level needed for discontinuing the sitter per the patient assessment and safety trials as the patient condition improves or declines ... An order to change sitter levels or to discontinue the sitter should be placed after team agreement. An example would be a brain injury patient who has shown some improvement in condition during the stay but continues to require a sitter in the evening hours would need an order for the sitter for those hours.” Review of Patient #1’s medical record revealed an admission date of 12/15/2023. Patient #1 had a fall on 01/2/2024 at 1:30 PM. Review of Patient #1’s medical record revealed a physician order for 1:1 sitter placed on 12/27/2023. Patient #1 suffered a fall on 01/02/2024 at 1:30 PM. Per the medical record review, there was no sitter in place at the time of the fall, despite the order remaining active at the time. During an interview with Chief Executive Officer (CEO) B on 03/26/2024 at 12:15 PM, CEO B stated nursing staff determined Patient #1 no longer met criteria for a sitter on 12/30/2023 and the 1:1 observation was discontinued. The discontinuation order was not placed until after the fall on 01/02/2024 at 6:42 PM. The sitter justification forms were not considered part of the permanent medical record and were not available for review during the survey making it was difficult to determine whether ongoing 1:1 observation needs were assessed as per policy. Review of Patient #9’s medical record revealed an admission date of 03/11/2024. Patient #1 had a fall on 03/17/2024 at 7:00 AM. Review of Patient #9’s medical record revealed Patient #9 suffered a fall on 03/17/2024. Per medical record review, Patient #9 was provided 1:1 observation (sitter) from 03/12/2024 until 03/17/2024. There was no physician order for continuous 1:1 observation found. During an interview with Regional Chief Nursing Officer (RCNO) I on 03/27/2024 at 12:08 PM, RCNO I stated nursing staff determined Patient #9 did meet criteria for a sitter, however stated “the scheduled sitter called in ill, and the facility was unable to find staff to provide the 1:1 continuous observation” for Patient #9. The sitter justification forms were not considered part of the permanent medical record and were not available for review during the survey making it was difficult to determine whether ongoing 1:1 observation needs were assessed as per policy. The facility did not determine or implement appropriate alternate methods to ensure Patient #9’s safety. Patient #9 suffered a fall during the time that 1:1 continuous observation was not provided due to lack of staff.”

“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: 29963 Based on record review and interview, the facility staff failed to follow policy with documentation for 2 of 4 patient falls (Patient #1 and #9) and failed to establish, document, and follow guidelines for interventions for patients at high risk for falls for 2 of 4 patients (Patient #1 and 9) in a total universe of 10 medical records reviewed. Findings include: A review of facility policy Version 2, titled, “Patient Falls Program” reviewed 09/05/2023 revealed, “Purpose: To identify patients at risk of falling so that appropriate interventions can be implemented ... High Fall Risk: Morse Fall Risk 45 or more or other identified concerns by any team member. All standard and Medium level interventions plus additional interventions may be deployed to further prevent a fall including, but not necessarily limited to, the following: bed alarm and /or chair alarm, consider the need for safety surveillance, use of assistive devices for postural support, mobility, and/or ambulation, consider increasing the frequency of observation and assistance to the patient for care needs. Any additional measures identified by the interdisciplinary team that may benefit the patient, such as moving closer to the nurse’s station when possible, or any other potential safety elements, such as mats by the bed. Documentation in the Medical Record- Patients assessed/reassessed as a risk for fall shall have said assessment/reassessment documented in their medical record. The medical record should also reflect documentation of interventions deployed to prevent a fall. If a fall occurs: Assess the patient for injury prior to moving. Notify physician and notify family member. Document the physical assessment and events in the chart and complete the post-fall assessment in the EMR (Electronic Medical Record). Conduct post fall assessment of the fall within 15 minutes of the fall and plan further interventions. An incident report should be completed and turned in to the quality department.” A review of facility guidelines titled, “One to One Sitter Justification Guidelines” undated revealed, “Any care team member can request a sitter for a patient. The Sitter Request Evaluation Form must be filled out by the requester and turned in to the CNO (Chief Nursing Officer), DQM (Director of Quality Management), or CTO (Chief Therapy Officer) (or designee if all 3 are unavailable) ...If the evaluation warrants the sitter need, the designated approver will notify the requester as soon as possible. If a sitter is needed prior to approval, the supervisor should be notified immediately in order to provide staff who are able to be a sitter during the approval time. An order for a sitter must be placed on the patient chart ... Plan of care should address the need for a sitter and the plan for addressing or discontinuing the sitter prior to any level discharge. The team should decide the safety level needed for discontinuing the sitter per the patient assessment and safety trials as the patient condition improves or declines ... An order to change sitter levels or to discontinue the sitter should be placed after team agreement. An example would be a brain injury patient who has shown some improvement in condition during the stay but continues to require a sitter in the evening hours would need an order for the sitter for those hours.” A review of Patient #1’s medical record revealed an admission date of 12/15/2023. Patient #1 had a fall on 01/02/2024 at 1:30 PM. A review of Patient #1’s Physician orders beginning 12/27/2023 at 6:00 PM through 01/02/2024 at 6:42 PM revealed, “Sitter 1:1 Continuously”. A review of documentation in Patient #1’s medical record and assignment sheets reveal that Patient #1 did not have a sitter on 01/02/2024 at 1:30 PM when Patient #1 had a fall. There was no evidence that a sitter was documented from 01/01/2024 at 6:30 PM through 01/02/2024 at 6:42 PM when the order was discontinued. A review of Patient #1’s medical record revealed assessments indicating Patient #1 no longer required a sitter based on criteria were not found in the medical record. Based on the facility’s current sitter guidelines, the sitter request forms are not considered a permanent part of the medical record. A review of Patient 1’s “Incident Report” dated 01/02/2024 revealed, “Incident/Fall Date: 01/02/2024 Incident Time: 1:30 PM. Admission date 12/15/2023. CNO (Chief Nursing Officer) notified that patient had fallen. Interviewed the CNA (Certified Nursing Assistant) who shared [s/he] was at the nursing desk and could visualize [Patient #1]. Could see [her/him] lean forward and hit head on floor ... The sitter order is still documented and not dc/d (discontinued) over the weekend, however the patient has not had a sitter for the last couple of days per RN (Registered Nurse) assessment.” During an interview on 03/26/2024 at 12:15 PM, the medical record review findings were discussed with and confirmed by Chief Executive Officer (CEO) B who stated, “[Patient #1] had a 1:1 sitter beginning on 12/27/2024 however daily assessments determined [Patient #1] no longer required a sitter based on criteria.” During an interview on 03/26/2024 at 2:00 PM, Nurse Practitioner F stated when asked about Patient #1, “If a sitter was ordered [for Patient #1] I assume there was a sitter with [her/him].” A review of Patient #1’s “RN Progress Notes” revealed, on 01/02/2024 after the fall at 1:30 PM, there was no RN Progress Note documented of the fall in Patient #1’s medical record. During an interview on 03/27/2024 at 1:45 PM, the medical record review findings were discussed with and confirmed by RN Supervisor E who stated there was no RN Progress Note documented addressing the fall on 01/02/2024. A review of Patient #9’s medical record revealed an admission date of 03/11/2024. Patient #9 had a fall on 03/17/2024 at 7:00 AM. A review of Patient #9’s Physician orders for 03/17/2024, there was no physician orders for a 1:1 sitter. Review of the medical record revealed evidence that assessments/care plan notes indicated Patient #9 met criteria for a sitter per policy and a sitter was provided and maintained continuously from 03/12/2024 through 03/17/2024 at 6:30 AM. During an interview on 03/27/2024 at 12:08 PM, the medical record review findings were discussed with and confirmed by Regional Chief Nursing Officer (RCNO) I who stated [Patient #9] had a sitter since admission into the hospital, a sitter order should have been written in the medical record. A review of Patient #9’s “Incident Report” dated 03/17/2024 revealed, “Incident/Fall Date: 03/17/2024 Incident Time: 7:00 AM. Admission date 03/11/2024. Sitter left without signing out with RN (Registered Nurse), next sitter called in. When sitter left [s/he] did not turn on bed alarm and pt exited bed and fell. No plan was made with RN about how to handle lack of staff. Pt. is confused at baseline. Follow up/Resolution: Per incident review, NOC (night) shift sitter left at end of shift and did not put alarm on. Day shift sitter called in. Per HS (House Supervisor) report, there was no staff to assume sitter responsibilities. Patient exited bed and fell to floor. Patient was attempting to get to bathroom. No injury. HS implemented increased rounding for safety. MD (Medical Doctor) and family notified.” A review of Patient #9’s “Rounding Documentation” dated 03/17/2024 revealed, rounding was completed by CNA V at “6:00 AM- sleeping, vitals 7:00 AM- (blank- not checked), 8:00 AM- sitting at the nurses station, 9:00 AM- (blank- not checked), 10:00 AM- bathroom/back in his chair, 11:00 AM- (blank- not checked), 12:00 PM-lunch in hallway with family, 1:00 PM- (blank- not checked), 2:00 PM- in bed, 3:00 PM- (blank- not checked), 4:00 PM-by window with the nurse, 5:00 PM- (blank- not checked), 6:00 PM- sitting at table in hallway.” There was no documentation that rounding was increased prior to or after Patient #9’s fall on 03/17/2024. A review of Patient #9’s “RN Progress Notes” revealed, on 03/17/2024 after the fall at 7:00 AM, there was no RN Progress Note documented of the fall. During an interview on 03/27/2024 at 10:00 AM, the medical record review findings were discussed with and confirmed by Director of Quality C who stated there was no RN Progress Note documented addressing the fall on 03/17/2024 per policy. During an interview on 03/27/2024 at 12:08 PM, the medical record review findings were discussed with and confirmed by Regional Chief Nursing Officer (RCNO) I who stated, “there was not a physician order for a 1:1 sitter, however it was determined that [Patient #9] needed a 1:1 sitter for safety. The night shift CNA (Certified Nursing Assistant) left at the end of the shift and did not turn the bed alarm on. The day shift CNA called in for the shift. Attempts were made to find a replacement but was not able to find anyone. After the fall, it was determined in the post fall huddle, rounding would be increased.” When RCNO I was asked what the facility actions were following the fall investigation, RCNO I stated, “The fall investigation is not complete yet.” During an interview on 03/28/2024 at 1:02 PM, Nurse Practitioner F stated, “Our current process allows any caregiver to implement a sitter for safety purposes.””