HospitalInspections.org

Based on policy review, observation, staff interview, medical record review, and patient interview the hospital's nursing staff failed to supervise and evaluate patient care by failing to implement falls precautions per policy and/or failing to reassess falls risk after a fall for 4 of 19 sampled patients at high risk for falls (Patient #5, #4, #8, and #9).

The findings include:

Review of current hospital policy entitled "Fall Risk Protocol" dated 11/2010 revealed, "All patients will be assessed for Fall Risk using the Hendrich II Fall Risk assessment on admission, twice within 24 hours not to exceed 16 hours, and when indicated. Safety strategies will be utilized and implemented as appropriate. All patients identified as being 'at high risk for falls' (score of 5 or more), will be placed on the Fall Risk Protocol and incorporate high risk strategies....If a patient falls during their hospitalization, the nurse will complete a Fall Risk Assessment/Reassessment at the time and implement the Fall Risk Protocol....Implement high risk safety strategies if Fall Risk Assessment score 5 or greater. 1. Place Fall Risk sign outside and/or inside room per facility routine....2. Place yellow Fall Risk ID band on patient....4. Implement additional high risk strategies on all patients as applicable....h. Bed/chair alarm if available....If patient is High Risk, document on the flowsheet the high risk strategies implemented."

1. Observation during tour of the 2 North Unit of the hospital's Campus A on 12/20/2010 at 1200 revealed a yellow Fall Risk sticker on the outside of room 2108's (Patient #5's room) closed door. Observation revealed the patient's nurse (RN #1) knocked on the door and entered the room. Observation revealed the patient was not in the room. Interview with RN #1 during the observation of the empty room revealed the nurse did not know the patient was not in her room. Interview revealed, "She left the floor with her friend again....She said she fell last night but no one saw it....She's oriented and knows exactly what she's doing." Interview revealed there was no bed alarm in use on the patient's bed. Interview revealed, "She knows she's supposed to call, she just doesn't call sometimes....I've been in here at least every hour this morning." Observation revealed a Rounding Sheet (with hourly lines for staff to sign when they made rounds) was posted in the patient's room. Review of the Rounding Sheet revealed the last time the sheet was signed was at 0900 (3 hours before observation). Observation revealed the nurse took the sheet and signed lines for 1000 and 1100 when the surveyor showed her the sheet. Interview revealed, "I've been in hourly, I just didn't sign it." Further interview revealed the nurse had assessed the patient to be at low risk for falls during her morning assessment, but had not yet charted it.

Open medical review on 12/20/2010 at 1215 for Patient #5 revealed a 38 year-old female that was admitted to room 2108 on the 2 North Unit of the hospital's Campus A on 12/18/2010 with HIV and "probable viral syndrome". Review of the admission nursing assessment on 12/18/2010 at 0238 revealed, "Fall Risk Score Total: 5. Safety/Alert Armbands in Place: ID and, Fall risk band....High Risk Safety Strategies: Assist pt (patient) w/ambulating or transferring, Assist to toilet before bedtime, Assist to toilet frequently while awake, Communicate fall risk in report & upon transfer, Communicate fall risk w/frequent observation, Frequent rounding, Use assistive devices as appropriate." Review of nurse's notes on 12/18/2010 at 0300 revealed the Fall Risk Score Total was 6 and the patient used a walker as an assistive device. Further review of nursing documentation of Fall Risk Score Totals revealed nursing staff assessed the patient to be at low risk for falls (score less than 5) on 12/18/2010 at 0800, 1400, and 2301 and on 12/19/2010 at 0900, 1420, and 2300. Review of nurse's notes on 12/20/2010 at 0033 revealed, "Pt went to bathroom without calling for assistance. Nursing assistant found pt on bathroom floor when answering bathroom call light. VS (vital signs) stable and WNL (within normal limits). No visible injury. Pt denies injury or pain resulting from fall. Supervisor notified." Record review at 1215 revealed no documentation the nurse reassessed the patient's Fall Risk after the patient fell (11 hours and 42 minutes prior to record review).

Further observation during tour of the 2 North Unit of the hospital's Campus A on 12/20/2010 at 1230 revealed Patient #5 was back in her room in bed. The patient's husband and walker were at her bedside. Observation revealed a sign on the wall beside the patient's bed that instructed the patient to call for help to get up. Interview with the patient's husband revealed, "They put a sign on the wall a couple of days ago to remind her. She knows she should call....She needs help to use the walker." Interview with the patient revealed the patient has "problems with short term memory" and sometimes forgets to call for help to get up.

Interview on 12/20/2010 at 1120 with the 2 North Nurse Manager during unit tour revealed nurses should assess all patients for falls risk at least once per shift. Interview revealed when a patient was assessed to be a high falls risk, the protocol that was implemented included a yellow sticker on the patient's door and a yellow bracelet on the patient's arm, to increase all staff's awareness to the risk. Interview revealed, "Sometimes we implement precautions even if the score does not indicate an increased risk (for falls), if per nursing judgement the patient is at risk." Further interview revealed, "(Staff) would use a bed alarm per nursing judgement....If a patient has fallen while getting up without calling for help or we noticed they have tried to get out of bed without help....A confused patient would be ideal to put on a bed alarm."

Interview on 12/20/2010 at 1120 with the Chief Nursing Officer during unit tour revealed, "Not all falls risk patients get bed alarms. We have 5 (bed alarms) available for this unit....We try to use them for patients that need them the most."

Further interview with the 2 North Nurse Manager on 12/20/2010 at 1215 revealed, "She (Patient #5) probably should have been put on a bed alarm after her fall." Interview revealed at the time of observation, only 2 other patients were at high falls risk and there were bed alarms available for use. Further interview revealed the nurse should have reassessed the patient's Fall Risk immediately after the fall on 12/20/2010 at 0033. Interview confirmed there was no documentation the nurse reassessed the patient's Fall Risk.

2. Observation during tour of the 2 North Unit of the hospital's Campus A on 12/20/2010 at 1115 revealed no yellow Fall Risk sticker on the outside of room 2131's (Patient #4's room) closed door. Upon entering the room, observation revealed the patient lying in bed with a visitor at the bedside. Observation revealed no yellow falls risk bracelet on either arm of the patient.

Open medical review on 12/20/2010 at 1130 for Patient #4 revealed a 52 year-old female that was admitted to the Surgical Intensive Care Unit of hospital's Campus A on 12/14/2010 with HIV and sepsis. Review of the admission nursing assessment on 12/14/2010 at 0751 revealed, "Fall Risk Score Total: 9. Safety/Alert Armbands in Place: ID and, Fall risk band....Low Risk Safety Strategies: Appropriate lighting, Assess elimination needs; assist as needed, Bed low and locked, Educate pt/family on safety strategies/fall prevention, Night light, Non-slip footwear, Orient to environment, Patient items, call light within reach, Room & floor free of obstacles." Review of nurse's notes on 12/14/2010 at 1900 revealed, "High Risk Safety Strategies Assist to toilet frequently while awake, Bed/chair alarm if available, Family/visitor at bedside, Frequent rounding." Further review of nursing documentation of Fall Risk Score Totals revealed nursing staff assessed the patient to be at low risk for falls (score less than 5) on 12/14/2010 at 1600 and 2000. Review of nursing documentation of Fall Risk Score Totals revealed nursing staff assessed the patient to be at high risk for falls (score of 5 or greater) on 12/15/2010 at 0000 and 1900; on 12/16/2010 at 0700 and 1900; and on 12/17/2010 at 0730 and 1900. Record review revealed documentation on 12/15/2010 and 12/16/2010 that the bed alarm was on. Record review revealed on the evening of 12/17/2010 the patient transferred to room 2131 on the 2 North unit. Record review revealed no documentation a bed alarm was in use after the patient transferred to the 2 North unit. Review of nursing documentation of Fall Risk Score Totals after the patient's transfer revealed the patient was assessed to be at low risk for falls (score less than 5) on 12/17/2010 at 2250 and on 12/19/2010 at 1529 and was assessed to be at high risk for falls (score of 5 or greater) on 12/18/2010 at 0800 and 1430; on 12/19/2010 at 0727 and 2300, and on 12/20/2010 at 0824. Record review revealed the last documentation the patient had on a fall risk ID band was on 12/29/2010 at 2300.

Interview on 12/20/2010 at 1120 with the 2 North Nurse Manager revealed during unit tour revealed nurses should assess all patients for falls risk at least once per shift. Interview revealed when a patient was assessed to be a high falls risk, the protocol that was implemented included a yellow sticker on the patient's door and a yellow bracelet on the patient's arm, to increase all staff's awareness to the risk. Interview revealed Patient #4 should have had a yellow sticker on her door and a yellow bracelet on her arm because she was at a high falls risk.

Interview on 12/20/2010 at 1130 during tour with the patient's assigned nurse (RN #2) revealed, "I assessed her this morning....found her to be a high falls risk....I don't know why she doesn't have a bracelet on or a sticker on her door. She must not have been at high risk per the previous nurse's assessment."

3. Observation during tour of the 2 West Unit of the hospital's Campus B on 12/21/2010 at 1020 revealed an assistant nurse manager (RN #3) walking down the hall checking patient rooms. Interview with RN #3 during the observation revealed the nurse was checking rooms and patients to ensure that falls precautions were in place for patients that had been assessed to be at high falls risk. Interview revealed such rounds were conducted each day. Interview revealed if the last falls risk assessment score was less than 5 the nurse removed the sign from the door. Continued observation at 1025 revealed no yellow Fall Risk sign on the outside of room 2232's (Patient #8's room) door.

Open medical review on 12/21/2010 at 1040 for Patient #8 revealed a 65 year-old female that was admitted to the 2 West unit of hospital's Campus B on 12/19/2010 with diagnoses of pneumonia and rule out pulmonary embolism. Review of the admission nursing assessment on 12/19/2010 at 2007 revealed, "Fall Risk Score Total: 7. Safety/Alert Armbands in Place: Fall risk band....High Risk Safety Strategies: Communicate fall risk w/frequent observation, Frequent rounding." Further review of nursing documentation of Fall Risk Score Totals revealed nursing staff assessed the patient to be at low risk for falls (score less than 5) on 12/19/2010 at 2010 and on 12/20/2010 at 0805 and 2200. Review of nurse's notes on 12/21/2010 at 0817 (2 hours prior to observation) revealed the Fall Risk Score Total was 10 (high falls risk). Record review revealed no documentation of other falls risk assessments.

Interview on 12/21/2010 at 1045 with the 2 West Nurse Manager revealed when a patient was assessed to be a high falls risk, the protocol that was implemented included a yellow sign on the patient's door, to increase all staff's awareness to the risk. Interview revealed, "The charge nurse or her designee rounds every day to ensure falls precautions are implemented." Interview revealed RN #3 had removed the sign from Patient #8's door just prior to the observation because the list of patients at risk for falls that she was using had been printed at about 0400, when the patient was assessed to be at low risk for falls. Interview confirmed the most recent falls risk assessment (at 0813) showed the patient to be at high risk for falls. Interview revealed Patient #8 should have had a yellow falls risk sign on her door.

4. Observation during tour of the 2 West Unit of the hospital's Campus B on 12/21/2010 at 1020 revealed an assistant nurse manager (RN #3) walking down the hall checking patient rooms. Interview with RN #3 during the observation revealed the nurse was checking rooms and patients to ensure that falls precautions were in place for patients that had been assessed to be at high falls risk. Interview revealed such rounds were conducted each day. Interview revealed if the last falls risk assessment score was less than 5 the nurse removed the sign from the door. Continued observation at 1025 revealed no yellow Fall Risk sign on the outside of room 2230's (Patient #9's room) door.

Open medical review on 12/21/2010 at 1040 for Patient #9 revealed a 62 year-old male that was admitted to the 2 West unit of hospital's Campus B on 12/19/2010 with a diagnosis of pulmonary embolism. Review of nursing documentation of Fall Risk Score Totals revealed nursing staff assessed the patient to be at low risk for falls (score less than 5) on 12/20/2010 at 0100, 0142, 0915, and 1959. Review of nurse's notes on 12/21/2102 at 0730 (2 hours and 50 minutes prior to observation) revealed, "Fall Risk Score Total: 5 (high falls risk). Safety/Alert Armbands in Place: ID band, Fall risk band....High Risk Safety Strategies: Assist pt (patient) w/ambulating or transferring, Cannot be unattended when transporting, Communicate fall risk in report & upon transfer, Communicate fall risk w/frequent observation, Family/visitor at bedside, Frequent rounding." Record review revealed no documentation of other falls risk assessments.

Interview on 12/21/2010 at 1045 with the 2 West Nurse Manager revealed when a patient was assessed to be a high falls risk, the protocol that was implemented included a yellow sign on the patient's door, to increase all staff's awareness to the risk. Interview revealed, "The charge nurse or her designee rounds every day to ensure falls precautions are implemented." Interview revealed RN #3 had removed the sign from Patient #9's door just prior to the observation because the list of patients at risk for falls that she was using had been printed at about 0400, when the patient was assessed to be at low risk for falls. Interview confirmed the most recent falls risk assessment (at 0730) showed the patient to be at high risk for falls. Interview revealed Patient #9 should have had a yellow falls risk sign on her door.


NC00069010