HCA Houston Healthcare North Cypress

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure two(2) of five sampled patients executed an appropriate and complete informed consent prior to undergoing a lumbar puncture ( Patient # 6, # 10) .

Findings include:

TX 100

Record review of five (5) patients who underwent lumbar puncture in the facility emergency room (ER) revealed the following:

Patient # 6:

Review of Patient # 6's clinical record revealed she was a [AGE] year old female who presented to ER on 05-21-15 with complaints of stiff neck, headache, sore back, and chills. Temperature upon arrival was 102.4 degrees

Review of Patient # 6's Disclosure and Consent form for a Lumbar Puncture revealed patient's signature but no date and no time. In addition, the sections that indicated the disclosure of risks was left blank and unmarked for epidural/spinal procedure, including lumbar puncture. The area that delineated procedure risks was not marked by the facility nor documented as acknowledged by Patient # 6.

Patient # 6 underwent a lumbar puncture on 05-21-15 at 1206 .

Patient # 10:

Review of Patient # 10's clinical record revealed she was a [AGE] year old female who presented to ER on 06-29-15 with complaints of headache, weakness, and dehydration.

Review of Patient # 10's Disclosure and Consent form for a Lumbar Puncture revealed the sections that indicated the disclosure of risks was left blank and unmarked for epidural/spinal procedure, including lumbar puncture. The area that delineated procedure risks was not marked by the facility nor documented as acknowledged by Patient # 6.

Patient #10 underwent a lumbar puncture on 06-30-15 at 0010.

Interview on 07-27-15 at 2:30 p.m. with Director of Quality/Risk # 2, she stated the consents should have dates, times, and applicable risks disclosed and acknowledged.

Record review of facility policy titled Informed Consent: Surgery/Procedure Consent, review/revised date 11/2012, read:....In accordance with state and federal law, prior to providing care, treatment , or services, consent will be obtained from either the patient or the patient's surrogate decision maker. A Disclosure and Consent for Medical and Surgical Procedures form must be used to document consent of the patients for performance of any of the procedures falling within the following categories: :...all procedures requiring administration of general, spinal, epidural or regional anesthesia....

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure that one of five sampled patients received procedure-specific discharge instructions after undergoing a lumbar puncture ( Patient # 5).

Findings include:

TX 100

Record review of five (5) patients who underwent lumbar puncture in the facility emergency room (ER) revealed that four of the five(5):

1. received printed discharge instructions titled Lumbar Puncture or

2. documented instructions in the medical record of specific content to post lumbar puncture.

Record review of the clinical record of Patient # 5 revealed she was a [AGE] year old female who presented on [DATE] at 2232 with complaints of acute low back pain, headache, and fever of 100.9 degrees Fahrenheit.

Patient # 5 underwent a lumbar puncture on 03-12-15 at 0135. She was discharged home on 03-12-15 at 0516.

Further review of Patient # 5's ER record revealed she was given printed discharge instructions for viral meningitis and none for lumbar puncture. Review of her clinical record read: ...Patient has been given discharge instructions both written and verbally... No specific mention of lumbar puncture was documented.

Interview on 07-27-15 at 2:30 p.m. with Director of Quality/Risk # 2, she acknowledged Patient # 5 should have received the printed instructions for lumbar puncture as did the other patients who had lumbar punctures.

Review of facility policy titled Emergency Department Discharge Instructions,revised date 04-15-15, read: ...2. The physician will review the diagnosis and... plan of care post discharge... 3. The registered nurse will review the discharge instructions...5. The signature page of the discharge instruction form is to be kept in the medical record...

Based on interview and record review, following an adverse event, the facility failed to fully analyze the causes and fully implement preventative measures to prevent reoccurrence. The facility failed to:

1. Identify a critical system failure regarding knowledge and communication of current professional literature concerning medication safety issues.

2. Evaluate potential risks regarding other patient care devices: multidose medication devices and multi-use patient care equipment.

3. Include all relevant team members in the Root Cause Analysis (RCA) process.

Findings include:

TX # 724

Record review of intake # 724, (facility-reported incident}, dated 01-14-14, revealed on 10-25-13 a facility nurse manager (Staff ID # 5) discovered that a staff nurse had been using a single patient insulin pen on multiple patients; thereby risking cross contamination of blood borne pathogens. The Chief Nursing Officer (CNO/ ID # 2) was immediately notified and he sent an email to all nursing managers informing them of the incident. He directed the nurse managers to remind their staff this was strictly a prohibited practice. The investigation was begun immediately and included the CNO interviewing all staff nurses regarding their understanding of the use of insulin pens.

1.

Record review on 01-17-14 of facility RCA, undated, failed to reveal the identification of critical information management breakdown related to the misuse of insulin pens.

Under RCA section labeled Information Management Issues, the facility documented that the Joint Commission (JC) coordinator sent Sentinel Event Alerts to all staff. There was no other issue listed under this section.

The facility failed to assess the process related to availability and dissemination of current literature related to medication safety and risks.

Interview on 01-17-14 at 2:30 p.m. with CNO / ID #2, he stated after the facility became aware of the misuse of the insulin pens, they began conducting research. The CNO went on to say the research showed this same issue had occurred at other facilities; until time of research they were unaware.

Continued record review on 01-16-14 of facility investigation revealed research compiled after the occurrences. Facility research included a 2009 Food and Drug Administration (FDA) Alert that cautioned sharing of insulin pens possibly transmitting of bloodborne diseases. In addition, facility research included information distributed in 2012 from Centers for Disease Control (CDC) and Centers for Medicare and Medicaid (CMS) both alerting to issues with misuse of insulin pens.

Review of FDA Alert dated March 19, 2009 read: ... (based upon exposure of 2,000+ patients at two healthcare facilities): ... The FDA reminds healthcare providers, healthcare facilities ... that each insulin pen (and each insulin pen cartridge) is designed for single-patient use only and is never to be shared among patients. Insulin pens are not designed, and are not safe, for one pen to be used for more than one patient, even if needles are changed between patients because any blood contamination of the pen reservoir could result in transmission of already existing blood-borne pathogens from the previous user ...

Interview in 01-17-14 at 9:30 a.m. with Quality Director ID # 4, she stated the process for disseminating medication safety information was not discussed as part of the RCA, but would be considered as they moved forward.

*[Please see related information under A-0495 citation Pharmacist Responsibilities. ]

2.

Continued review of facility RCA, undated, failed to reveal the identification of other pen-like medication devices or other point of care devices that may place patients at risk of transmission of bloodborne pathogens.

Interview on 01-17-14 at 1:10 p.m. with Chief Operating Officer (COO) ID # 1 he stated he informally asked the pharmacy and laboratory directors to review their processes and protocols for other possible devices. He went on to say they would conduct further review as they moved forward.

Interview on 01-17-14 at 2:20 p.m. with Laboratory Director /ID # 21, he stated the facility used the following multi-patient use devices: glucometers (all nursing units), I-STAT machines (in the Operating Rooms (OR), emergency room (ER), and imaging departments) ; Hemochron machines(Cath lab, OR, ER, and ICU).

The Laboratory Director/ID # 21 went on to say he was in the process of revising the competencies, which were required upon hire and annually thereafter. He acknowledged the glucometers, ISTAT, and Hemochron machines were all point-of-care / multi-patient use devices. He said the machines must be cleaned appropriately between patient use for infection control purposes.

3.

Interview in 01-17-14 at 9:30 a.m. with Quality Director / Staff ID # 4 she stated the COO /Staff ID # 1 and CNO /Staff ID # 2 were coordinating the investigation, along with the Pharmacist ID # 8. The Quality Director /ID # 4 said she documented actions taken on the RCA form. She acknowledged the Infection Control Practitioner, ID # 20 was not actively involved in the RCA.

Interview on 01-17-14 at 3: 35 p.m. with Infection Control Practitioner, ID # 20 she stated she had been in her position for one and one-half years. She said she was aware of the misuse of insulin pen incident but did not participate in the RCA or other aspects of the investigation or improvement plan.

Record review of facility policy titled Event Reporting, review date 07/13, read: ...The Framework (RCA) will focus on systems and processes, not on individual performance. During the development of the framework document, the 2 Why ' s will be asked ...the goal is to determine if there are opportunities for a process re-design to improve patient safety and efficiency.. (JC Comprehensive Accreditation Manual of Hospitals (January 2013)

Based on interview and record review, the facility pharmacist failed to supervise and coordinate all activities of the pharmacy services. The pharmacist failed to evaluate and disseminate current medication safety information regarding misuse of insulin pens.

Findings include:

TX # 724

Record review of facility-reported incident, dated 01-14-14, revealed on 10-25-13 a facility nurse manager (Staff ID # 5) discovered that a staff nurse had been using a single patient insulin pen on multiple patients; thereby risking cross contamination of blood borne pathogens. The Chief Nursing Officer (CNO/ ID # 2) was immediately notified an investigation was begun. The CNO began interviewing all staff nurses regarding their understanding of the use of insulin pens.

Interview on 01-17-14 at 2:30 p.m. with CNO / ID #2, he stated after the facility became aware of the misuse of the insulin pens, they began doing research. The CNO went on to say the research showed this same issue had occurred at other facilities; until time of research they were unaware.

Continued record review on 01-16-14 of facility investigation revealed research compiled after the occurrences. Facility research included a 2009 Food and Drug Administration (FDA) Alert that cautioned sharing of insulin pens possibly transmitting of bloodborne diseases. In addition, facility research included information distributed in 2012 from Centers for Disease Control (CDC) and Centers for Medicare and Medicaid (CMS) alerting to issues with misuse if insulin pens.

Telephone interview on 01-24-14 at 3:30 p.m. with facility Director of Pharmacy/ID # 22 he reported he had been in his position at the facility since October 2009. He went on to say the insulin pens had been used at the facility since January 2009.

Pharmacy Director ID # 22 reported he had access to multiple sources and publications regarding medication safety. He subscribed to the ' American Society of Health-System Pharmacists (ASHP) Journal ' , ' Hospital Pharmacy Times, ' Food & Drug Administration (FDA) Alerts, Institute for Safe Medication Practices (ISMP) Newsletter and other publications.

When asked if he was aware of the FDA Alert 2009 and various ISMP Medication Safety Alerts of 2009 & 2013 regarding insulin pen misuse, Pharmacy Director ID # 22 acknowledged that information did not come his way.

He went onto say the hospital formulary included 4,000 medications and many issues were monitored including: look-alike sound alike drugs, high alert medications, adverse drug reactions (ADR) and others.

Record review on 01-16-14 of FDA Alert dated March 19, 2009 read: ... (based upon exposure of 2,000+ patients at two healthcare facilities): ... The FDA reminds healthcare providers, healthcare facilities ... that each insulin pen (and each insulin pen cartridge) is designed for single-patient use only and is never to be shared among patients. Insulin pens are not designed, and are not safe, for one pen to be used for more than one patient, even if needles are changed between patients because any blood contamination of the pen reservoir could result in transmission of already existing blood-borne pathogens from the previous user ...

Record review on 01-16-14 of ISMP Medication Safety Alerts revealed:

ISMP Alert dated February12, 2009: discussion of misuse of insulin pens at a U.S. Army Hospital, exposure of 2,114 paints. Facilities using insulin pens should act immediately and provide education and continuous monitoring where an individual pen might be reused for another patient ... don ' t assume that everyone knows not to do this. In one report, a nurse told us that rather than waiting for pharmacy to dispense a patient ' s pen, nurses at her hospital often borrowed a pen from another patient, put in a new disposable needle and injected insulin into the second patient using the first patient ' s pen ...

ISMP Alert dated January 24, 2013: reported insulin pen used on multiple patients at a NY hospital, exposure of more than 700 patients to HIV, Hepatitis B, Hepatitis C.

ISMP Alert dated February 7, 2013: As a result of persistent ongoing safety issues, the ISMP is calling for hospitals to closely reexamine their policies regarding insulin pen devices, and consider transitioning away from insulin pens for routine inpatient use...

Interview on 01-17-14 at 1:10 p.m. with Chief Operating Officer (COO) ID # 1 he stated he provided direct oversight of Pharmacy Services. He went on to say that he questioned the pharmacist after the insulin pen occurrence regarding medication alerts and information regarding the insulin pens. He acknowledged this was a process the facility would address as they moved forward.

Based on , record review and interview the facility failed to ensure staff evaluate the safety needs of patients by adhering to the facility's fire responsibility protocol # EC.5.10.4.b dated 4/2011 . This failed practice resulted in adverse patient event. Citing all 24 patients on Unit 2.

Findings:

Review of complaint narrative TX 147 revealed information that on 12/13/11 a visitor smelled smoke on unit two (2) and informed two unit staff of the incident. The complainant documented staff did not do a thorough search and there was a fire in a patient's room resulting in a patient sustaining burns and other patients inhaled smoke.

During an interview on 3/21/11 at 9:40 am at the facility with Staff # 50 Registered Nurse she stated a visitor told her there was the smell of smoke and that it was coming from room # 2305. according to the Staff she did look into the room and two other patient's rooms and although she smelled smoke she did not see anything. The staff stated she did not report the smell of smoke or the visitor's concern to the other staff on the unit and she did not sound the fire alarm.

She went to the Lunch room on break for a few minutes when she heard the alarm of fire. The fire was in room 2305.

During an interview with Staff # 51 Patient Care Technician she stated the visitor told her that there was a smell of smoke, according to the Staff she smelt smoke checked the stairwell and patient rooms in the area she was working but did not see any smoke. According to the Staff she thought the smoke might have come form some visitors clothing who were near the stairwell. According to Staff # 51 she reported the information to the Nurse but she did not activate the fire alarm.

During the interviews they staff stated they did not activate the fire alarm because they did not see fire or smoke.

Review of the facility's Fire Policy # EC.5.10.4.b dated 4/2011 gave the following information:

In order to assure the safety of patients, visitors, and staff, a standard response to fire, or to the potential of fire, defined plans are required. This fire plan describes the standard response for all staff within the hospital to an activation of the Fire Alarm or to conditions that indicate the presence of a fire in the area.

The staff on the unit were informed of the potential for a fire and they failed to activate the fire alarm system per protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, and interview, the facility failed to develop a patient plan of care that instructs patient on safety precautions while on oxygen therapy. This failed practice had the potential to adversely affect all patients on the unit receiving oxygen therapy. Citing three of three patients receiving oxygen therapy, patient 3s (1, 2 and 3).

Findings:

Review of Physician ' s history and physical dated 12/10/11 for Patient # 1 revealed the [AGE] year old patient was admitted on [DATE] with admitting diagnosis of Chronic Obstructive Pulmonary Disease (COPD). There was documentation that her mental status was evaluated as being alert and oriented times three (person, time, and place). The patient was bed bound.

Review of nurses ' notes dated 12/12/11 revealed the patient was placed on oxygen therapy via nasal canulae. There was no documentation that the danger of smoking or using fire apparatus while on oxygen was discussed with the patient/family.

Review of nurses notes dated 12/13/11 documented the patient tried to light a cigarette while in bed with her oxygen canulae in place, the action resulted in a flash fire which burned her face.

Patient # 2

Review of physician ' s History and Physical dated 11/29/11 revealed the [AGE] year old patient was admitted on [DATE] intubated and on a vent due to respiratory failure.

Review of nurses ' notes revealed the patient was taken off the ventilator on 12/4/11 and placed on oxygen via nasal canula. The patient was on oxygen therapy until 1/2/12.

There was no documentation that the danger of smoking or using fire apparatus while on oxygen was discussed with the patient/family.

Patient # 3

Review of physician ' s History and Physical dated 11/29/11 revealed the [AGE] year old patient was admitted on [DATE] with dyspnea and increasing shortness of breath. The patient also had Chonic Obstructive Pulmonary Disease and was on oxygen at home via nasal canula. The patient had history of smoking in the past.

Review of nurses ' notes dated 12/12/11 revealed the patient was placed on oxygen via nasal canula until discharge on 12/14/11. There was no documentation that the danger of smoking or using fire apparatus while on oxygen was discussed with the patient/family.

Review of the facility ' s safety plan revealed no information that smoking or using flame while oxygen is in use could spark a fire.

During an interview on 3/21/12 at 10:35 am with facility ' s Nurse Administrative staff they stated there was no policy that addresses fire hazard while using oxygen in patients ' rooms.

Review of the facility ' s Smoking policy # EC.02.01.03 dated 2/2011 revealed information that patient would be informed of the facility ' s no smoking policy, review of the information given to patient ' s on admission only inform patients of the health risks of smoking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to implement it's grievance policy dated January 2010 to resolve patient complaints concerning quality of care and to inform them in writing the steps that were taken to investigate and resolve the complaint. The facility did not respond in writing to a family's complaints, citing one patient identified in a complaint TX 246. (Patient # 1).

Findings:

Review of complaint narrative written by Complainant J, on behalf of patient # 1 revealed the complainant had the following care concerns:

(a) Ninety eight (98) years old Patient #1, was given the drug Morphine(pain medication) which had a as needed (PRN) order without the patient asking for pain medications, as a result the patient became very drowsy and dizzy. According to the complainant the facility did not use good judgement.

(a) Staff did not respond in a timely manner when the patient called for assistance to the rest room.

(c) the patient fell out of bed and the bed alarm was not activated although the patient was labeled high risk for fall.

(d) Complainant spoke to several different staff who told her they would look into her concerns,but no one ever responded.

During a telephone interview on 4/11/11 at 2:30 pm with complainant J, she stated she spoke with administrative staff regarding her concerns but to date no one had responded to her concerns.

Review of the hospitals complaint records revealed no documentation that the complainant had voiced concerns regarding the care and services patient # 1 received.

Review of admission record for patient # 1 revealed she was admitted to the facility on on [DATE] and again in March 2011.

Review of nurses notes dated 2/11/11 revealed documentation that the patient's niece had concerns regarding medication that her aunt was given because she was more confused as compared to earlier. Further review of progress notes and nurses notes for the February and March admissions revealed no documentation in the patient's record that patient or family had other care concerns.

Review of nurses notes dated February 15, 2011 revealed documentation that Staff # 50, Chief Nursing Officer(CNO) was in the patient's room talking to her niece

During the investigation the Surveyor verified that Complainant J discussed her concerns with unit and administrative staff,however no one responded to her concerns.

During an interview with Staff # 51, Quality Coordinator she stated Ms. J, ( Complainant) had a discussion with her regarding her dissatisfaction with the nursing staff giving Patient # 1 Morphine when it was not indicated. According to Staff # 51, the complainant stated she felt Morphine was given to the patient to keep her sedated so staff would not have to take her to the rest room during the night.

Staff # 51 also stated the complainant told her that staffs were also putting the patient in diaper and her aunt never wore diapers before.

During an interview on 4/12/11 with Staff # 52, Nursing Director she stated she remembered having several discussions with Patient # 1's niece who had concerns regarding her Aunt ' s care.

During an interview on 4/12/11 at 11:45 am at the facility with Staff # 50 (CNO) she stated Complainant J , made a complaint to her, that the patient was given Morphine which made her dizzy and that she was never given morphine for her pain before and that the patient did not ask for any pain medication.

According to Staff # 50 she investigated and found there was a PRN (give as needed) order for the morphine. There was also documentation that the patient was in pain. The CNO further stated she did not document the complaint or the investigation and did not respond to the complainant in writing because the patient was an in- patient and the concerns were not considered a grievance.

Review of the facility's grievance policy dated January 2010 revealed that:

A patient grievance is a formal or informal written or verbal complaint that is made when a patient issue cannot be resolved promptly on the spot by staff present. Within 7 days of the grievance , a letter will be submitted to the complainant that includes results of the grievance investigation, corrective action as necessary.

The facility failed to respond to Complainant J in writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to ensure that a patient's condition was assessed when she was found lying on the floor in her room; failed to assess for adverse effects after medication was administered per the facility's protocol.

The facility failed to provide documentation that the physician was informed when a patient was found on the bathroom floor in his room.

The facility failed to follow their fall protocol to document incidents of falls in the patient's clinical record, citing two (2) of four (4) sampled patients that fell in the facility.

Findings:

During a pre investigation telephone interview on 4/11/11 with Complainant J, she informed the Surveyor that Patient # 1 was admitted in the facility in March 2011 and she arrived at the hospital one morning and was informed the patient was found on the floor.

According to Ms. J ,she spoke with the nurses and found out that prior to the fall, despite the fact Patient # 1 was on fall alert the bed alarm was never activated.

According to Complainant J, Patient # 1 had a large bruise on her shoulder and along her rib cage which remained tender to touch for a long time. According to the complainant she was not aware that an X-ray of the patient's shoulder was ever done to determine if there was a fracture.

Review of facility ' s fall reduction policy dated November 2010 revealed the following information:

The scope is to effectively identify patients who were at risk for falls, to prevent patient falls and protect patients from injury and to enhance patient safety. All patients are assessed after a fall and the physician notified. Determine level of injury. If unable to determine level of injury at time of the fall, do so with a follow-up of event.

The assessment is documented in the patient ' s medical record.

The policy did not clearly instruct staff to conduct a follow up assessment of patients when they fall to ensure that any missed injury at time of initial assessment does not go undetected in order to promote patient safety.

Patient # 1

Review of emergency room (ER) records revealed Patient # 1 (MDS) dated [DATE] with complaints of lethargy for over a week. She had not had much of an appetite for the past few days. B/P 135/72, Pulse 59, respiration 18. She was oriented to person only.

She was admitted to the unit where a physician ' s history and physical was completed. The physician diagnosed that the patient had Altered Mental Status and generalized weakness.

Review of the nurses admission notes dated 3/18/11 at 2314 pm documented the patient was coherent but confused and forgetful at times. At 1849 pm there was documentation that the patient was in bed and was on fall risk.

Further review of the nurses ' notes revealed that on 3/23/11 at 0111 an order for CT(Computerized Tomography) of head was made by the physician.

Subsequent nursing documentation revealed documentation that bed alarm was on.

Prior to 3/23/11 at 0301 there was no documentation that the patient ' s bed alarm was on, however there was continuous documentation that the patient was confused and forgetful.

There was documentation that Patient # 1 was discharged from the facility on the evening of 3/24/11.

There was no documentation that the patient was found on the floor in her room, nor that the patient was evaluated for injury. There was no documentation of a follow up assessment.

There was documentation that in the early morning of 3/23/11 the physician ordered a CT of head but no mention the patient fell .

The physicians ' discharge summary dated 3/25/11 documented the patient had an episode of fall and had a CT of head which showed no abnormality.

Review of incident reports for fall revealed there was a fall risk worksheet that was initiated which stated the patient was found lying on the floor next to her bed. There was no assessment documented on the form or medical record. The fall incident was never mentioned on the patient's medical record.

Review of nurses dated 2/13/11 revealed documented that at 2325 pm patient # 1 was still not asleep restless, given Xanax ( sedative) to calm her down.

Review of nurses notes dated 2/14/11 at four (4) minutes past midnight revealed documentation that Patient # 1 complained of a dull pain in her back, especially when she moves B/P 164/87, heart rate 85, will give pain medication.

Documentation at 19 minutes after midnight revealed the patient was given 4 mg of Morphine IV.( less than an hour after the sedative xanax was administered).

There was no documentation that the patient was ever re assessed for any adverse effects of the Morphine or Xanax.

Review of the facility's Pain Management Policy revised April 2010 documented that the policy's goal is to:

assess, evaluate and manage patient's level of pain upon admission and through out the hospital stay. The policy documented there would be assessment after each pain management intervention once sufficient time has elapsed for the treatment to reach peak effect. There was no documentation that the patient was assessed after the administration of a sedative and pain medication.

Patient # 2

Review of clinical record for Patient # 2 revealed she was [AGE] year old female admitted to the facility on [DATE]. Her chief complaint was syncope several times in the past 5 days especially when getting up.

There was documentation dated 2/11/11 at 1310 that the patient was found sitting on the bathroom floor. She was assisted back to bed. There were no injuries, vital sign blood pressure (B/P) 108/77, and pulse 89. The patient denied pain. Call light placed within reach. Red socks applied instructed to call for assistance. Will monitor.

There was no documentation that the physician was informed or that the staff re-assessed the patient.

During an interview on 4/12/11 with Staff # 53, Director of Risk Management regarding the allegations of patient falling out of bed, she stated she was not aware the patient had fallen until the Surveyor mentioned it. She presented a fall incident which she stated was initiated but was not completed according to the facility ' s protocol for completing a fall risk assessment.

Staff # 53 further stated that staff were required to assess all patients after medication is administered. She also stated it is expected that all patients are re-assessed after a fall to ensure no injury was missed.