HospitalInspections.org

Based on document review, medical record review and interviews it was revealed the hospital failed to evaluate the care of the patient by not following their Fall policy and procedure for notification of family and not implementing the Post Fall Nursing Order Set Care Bundle in patients experiencing a fall for three (3) of thirty (30) patients (patients #1, #7 and #8). This failure has the potential to adversely affect the care of all patients who experience a fall.

Findings include:

1. A review of the policy entitled 'Fall Prevention Program (Nursing)' with a publication date of 03/27/2018 revealed in part: "If patient falls, the Post Fall Nursing Order set Care Bundle will be implemented ...A physical assessment with immediate medical attention and provider and family notification will be performed."

2. A review of the medical record for patients #1, #7 and #8 revealed there was no documentation of family notification after the patient experienced a fall.

3. A review of the medical record for patients #1, #7 and #8 revealed the Post Fall Nursing Order Set Care Bundle was not implemented after the patient experienced a fall.

4. An interview conducted on 10/14/19 at approximately 2:20 p.m. with the Registered Nurse (RN) caring for patient #1 revealed she did not notify the patient's family after the patient experienced a fall.

5. An interview was conducted with the Three South (3 South) Nurse Manager on 10/15/19 at approximately 1:30 p.m. and she concurred with the above findings for patient #1.

6. The Corporate Director of Regulatory Compliance concurred with the above findings for patients #7 and #8 on 10/15/19 at approximately 2:50 p.m.