HospitalInspections.org

Based on a review of documentation and interview the facility failed to provide care in a safe setting by failing to ensure neurological assessment were effectively completed for patients post fall

Finding included:

Facility based policy 3.030 entitled, "Fall Prevention Protocol" stated in part,
"D. Post Fall Management ...
4. Take the following actions in the event of a witnessed fall, in which patient is known to have sustained no head trauma from the fall:
a. Check for injuries:
i. Check blood pressure and pulse sitting and standing (if patient is able to stand).
ii. If indicated, check capillary blood glucose or obtain a physician's order to check blood glucose, unless the delay in obtaining the physician's order will be a barrier to effective emergency response, timely and necessary care, or other patient safety advances.
b. For a maximum of 48 hours following the fall and/or until discharge:
i. Obtain vital signs every 4 hours.
ii. Observe for possible injuries not evident at the time, e.g. joint range of motion, weight bearing, etc.
iii. Observe for change in mental status, if noted, notify physician.
iv. Determine need for restrictions in mobility that may be warranted as a result of the fall.
5. In the event of an unwitnessed fall, or one in which the patient sustains head trauma, or in which there is uncertainty about any head trauma :
a. Use the same protocol outlined above.
b. Alert the physician to anticoagulant use in any patient who has fallen.
c. If patient needs immediate attention, call the rapid response team.
d. In addition, perform neurological checks every 15 minutes x 4, every 30 minutes x 2, every hour x 4, and then every 4 hours for 24 hours. Alert the attending physician to any changes."

* In an interview on 06/22/21 staff member #4 clarified that the facility standard of care and expectation is to complete vital sign checks every 4 hours for 48 hours post any unwitnessed fall.

Review of medical records revealed 4 of 5 patients (#4, 6, 7, 9, and 10) had issues with documentation of neurological assessments post fall per facility policy.

Patient #4 had an unwitnessed fall with head involvement on 01/16/21 at approximately 0410.
Review of Neuro checks for Patient #4 revealed the were performed on the following times on the day of the fall:
01/16/21 at 0500
01/16/21 at 0530
01/16/21 at 0630
01/16/21 at 0700
01/16/21 at 0800
01/16/21 at 0900
01/16/21 at 1000
01/16/21 at 1400
01/16/21 at 1757
01/17/21 at 0718

Based on the above documentation neuro checks were only completed every 30 minutes X 2, every hour X 4. The checks from 1000-1400 are 6 hours apart and the checks from 1400-1757 are over 3 hours apart. This does not meet the standard set by the facility policy for unwitnessed falls.

Patient #6 had an unwitnessed fall on 05/31/21 at approximately 11:26.
Review of documentation for Patient #6 revealed neurological checks were completed on the following times on the day of the fall:
05/13/21 at 1126 only documented orientation, pain, and temperature.
05/13/21 at 1200 only noted alert consciousness.
05/13/21 at 1230 only noted temperature.
05/13/21 at 1300 had orientation and pupillary assessment noted.
05/13/21 at 1531 only noted temperature.
05/13/21 at 2041 only noted temperature.
05/13/21 at 2106 only noted alert consciousness.
05/15/21 at 2354 only noted appears sleeping.

Based on the above documentation neuro checks were not completed per policy, the above neurological assessments were not complete. The only assessment of pupils and neurological status was documented at 1300. From 1300-2400 there was no complete neurological assessment of the patient. This does not meet the standard set by the facility policy for unwitnessed falls.
Patient #7 had a witnessed fall on 06/06/21 at approximately 09:30.
Review of documentation for Patient #7 revealed vital signs were checked on the following times on the day of the fall:
06/06/21 at 1003
06/06/21 at 1102
06/06/21 at 1219
06/06/21 at 1640
06/07/21 at 0000

Based on the above documentation no neuro checks were completed per policy, only vital signs
were only completed hourly X 3. The checks from 1219-1640 over 4 hours apart and the checks from 1640-0000 are over 7 hours apart. This does not meet the standard set by the facility policy for witnessed falls.

Patient #9 had an unwitnessed fall on 04/13/21 at approximately 11:38.
Review of documentation for Patient #9 revealed vital signs were checked on the following times on the day of the fall:
04/13/21 at 11:30
04/13/21 at 1259
04/13/21 at 1315 only pulse noted.
04/13/21 at 1315 only pulse noted.
04/13/21 at 1531
04/13/21 at 1639 only pulse noted.
04/13/21 at 1836 only pulse noted.
04/13/21 at 1920
04/13/21 at 1937
04/13/21 at 2000 only pulse noted.
04/13/21 at 2041 only pulse oximetry and FiO2 noted.
04/13/21 at 2125
04/13/21 at 2129
04/13/21 at 2330 only pulse noted.
04/13/21 at 2304 only pulse noted.
04/13/21 at 2219
04/13/21 at 2220
04/13/21 at 2221


Based on the above documentation no neuro checks were completed per policy, only vital signs
were only completed. Vital signs were not monitored effectively, only pulse was noted for several assessments. This does not meet the standard set by the facility policy for unwitnessed falls.

The above finding were verified with staff member #4 on 06/22/21, by failing to complete appropriate neurological assessments on patients post fall there is increased risk of the facility not identifying severe injury or neurological issues for early intervention and treatment post fall, increasing the potential for poor outcomes of patients post fall events.