HospitalInspections.org

Based on interview, record review and review of the facility's "Fall Prevention Policy" and "When a Fall Occurs" guidelines, it was determined the facility failed to ensure all patient medical record entries were complete by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures for three (3) of ten (10) sampled patients (Patient #2, #3, and #6).

The findings include:

Review of the hospital "Fall Prevention Policy" effective 01/1997 and revised on 11/2014, revealed it was the objective of the hospital to promote patient safety by identifying patients at risk for falls; to systematically assess fall risk factors; to provide guidelines for fall preventative interventions; and to outline procedures for documentation and communication; thereby, lowering the patient fall and fall related injury rate.

Review of the hospital "When a Fall Occurs" guidelines, undated, revealed complete Assessment of Patient; notify Medical Doctor (MD); validate and verify all specific procedures in comments as "post fall"; notify House Administrator and complete Post Fall Quality Reaction Form as a team and turn in to Chief Nursing Officer (CNO) and Quality Department; complete post fall documentation in EMR; complete IRIS (incident report); and complete a new Fall Risk Score Screening Assessment.

1. Review of Patient #2's EMR revealed the hospital admitted the patient on 10/16/14 with diagnoses including History of fall at home and Right Hip Pain. Review of the X-Ray dated 10/16/14, of the right hip and femur revealed the patient had a Right Hip Fracture. Review of the patient's Post Operative Report dated 10/17/15, revealed the patient was taken to surgery for a Gamma Nail Fixation of the right hip fracture.

Review of the hospital Fall Report List revealed Patient #2 sustained a fall on 10/20/14. Review of the Hospital Discharge Summary dated 10/21/14, revealed the patient sustained a fall the night of 10/20/14 receiving a superficial laceration to the chin that was managed with glue. However, there was no further documented evidence in the EMR including the Event Notes (a note used to document an event, incident, or occurrence), or Nurse's Notes indicating the fall with injury occurred.

Phone interview on 11/10/15 at 10:07 AM, with Registered Nurse (RN) #3 who was assigned to Patient #2 on 10/20/14 from 7:00 AM to 7:00 PM, revealed she could not remember the patient. However, RN #3 stated if the patient sustained a fall she would have assessed the patient for injury, notified the charge nurse, the house supervisor, and the attending physician of the fall, and would have notified the family/responsible party if needed. RN #3 stated, the fall and notifications should have been documented in an Event Note in the Adhoc section of the EMR.

2. Review of Patient #3's EMR revealed the hospital admitted the patient on 07/06/15 with diagnoses including Chronic Obstructive Pulmonary Disease Exacerbation and Left Lower Extremity Cellulitis.

Review of the hospitals Fall Report List revealed the patient sustained a fall on 07/10/15. However, there was no documented evidence in the patients EMR the fall had occurred.

Phone interview on 11/10/15 at 10:29 AM, with RN #2 who was assigned to Patient #3 on 07/10/15, revealed she had no memory of the patient. However, RN #2 stated if the patient fell while she was assigned, she would have assessed the patient for injury, notified the charge nurse, the house supervisor, and the attending physician of the fall, and would have notified the family/responsible party if needed. RN #2 stated she did not recall the incident but the nurse who was assigned at the time of the fall should have documented an Event Note in the EMR about the fall.

3. Review of Patient #6's EMR revealed the hospital admitted the patient on 02/23/15 with diagnoses including Urinary Tract Infection with a chief complaint of right flank pain.

Review of the hospitals Fall Report List revealed Patient #6 sustained a fall on 03/03/15. However, there was no documented evidence in the patients EMR the fall had occurred.

Phone interview on 11/10/15 at 10:29 AM, with RN #4 who was assigned to Patient #6 on the 7:00 AM to 7:00 PM shift on 03/03/15, revealed she did not remember caring for Patient #6 or the fall incident. However, RN #4 stated if she had found the patient in the floor after a fall she would have assessed the patient for injury, notified the charge nurse, the house supervisor, and the attending physician of the fall, and would have notified the family/responsible party if needed. RN #4 stated she would have documented the fall in an Event Note in the EMR.

Interview, on 11/12/15 at 3:00 PM, with the Medical Surgical Unit Manager #1 who managed the nursing staff caring for Patients #2, #3 and #6, revealed the primary nurse should have ensured there was documentation of the falls in an Event Note located in the Adhoc section of the patients' EMR for Patients #2, #3, and #6.

Interview with the Cheif Nursing Officer (CNO), on 11/12/15 at 3:15 PM, revealed the hospital nursing staff should have followed the facility's policy and guidelines after these patients sustained falls. Further interview revealed the nurse caring for the patient was responsible for documenting the falls in the Adhoc Event Note in the EMR.