Inspire Behavioral Health

Review of facility P&P further indicated .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.3.Review of Resident 124's clinical record indicated Resident 124 was transferred out of the facility to a GACH on 3/8/25, because of the fall that occurred on 3/7/25.

Review of Resident 124's clinical record document titled SBAR Post Fall, dated 3/7/25, indicated in section R.

Response to Xray of left hip and left leg, Neurocheck [a quick examination to evaluate brain function after a potential brain injury] per facility protocol, Orthostatic BP x72 hours.

Further review of Resident 124's clinical record indicated there were no orthostatic blood pressure measurements recorded for five eight-hour shifts between 3/7/25 at 8:30 AM and 3/8/25 at 7:46 PM (the day the resident was transferred to a GACH).

Further review also indicated in the SBAR Post Fall, completed on 2/17/25, Question 7 SYSTOLIC BLOOD PRESSURE was marked for the response No noted drop between lying and standing.During a concurrent interview and record review with the DON on 11/5/25 at 10:54 AM, the DON confirmed that there were no recorded orthostatic vital signs for Resident 124 between 3/7/25 and 3/8/25, and that the response for Question 7 on the SBAR Post Fall completed on 3/7/25 was not accurate.

The DON also said The nurses will sometimes check the orthostatic vitals on the spot but will not record them unless there was a concern.Review of facility P&P titled Blood Pressure, Measuring, revised September 2010, indicated .Documentation.

The following information should be recorded in the resident's medical record.The date and time the blood pressure was measured.The name and title of the individual(s) who measured the blood pressure.The blood pressure reading.If the resident refused the treatment, the reason(s) why and the intervention taken.The signature and title of the person recording the data.

Facility ID:

05A277