HospitalInspections.org

Based on policy and procedure review, medical record review, document review, and personnel interview, nursing staff failed to supervise and evaluate the nursing care for each patient related to lack of notification of patient's family/significant other post-fall for 3 of 6 (Patient #6, 8, and 10) closed patient medical records (MR) of patients who sustained a fall.

Findings:

1. Policy #PC_07, titled "Risk for Fall and/or Entrapment Guidelines" revised/reapproved 2/12/15, was reviewed on 2/23/15 at approximately 1:00 PM, and indicated patient's family/significant other is to be notified by staff of a fall.

2. Review of open and closed patient medical records on 2/23/15 at approximately 1130 hours, confirmed:
A. Patient 6's MR indicated the following:
a. Fell on 1/13/15 at 1930 hours and stated "tried to get up in the bed, but overestimated it" and was assisted back to bed without incidence or evidence of injury.
b. Lack of notification of patient's family/significant other of the fall.

B. Patient 8's MR indicated the following:
a. Fell on 11/12/14 at 1810 hours and had been in the bathroom but came out unassisted, was reinstructed on using call light for assistance with getting up.
b. Lack of notification of patient's family/significant other of the fall.

C. Patient 10's MR indicated the following:
a. Fell on 11/11/14 at 0020 hours and stated "forgot urinal was next to bed"; patient attempted to get up to the bathroom.
b. Lack of notification of patient's family/significant other of the fall.

3. Staff #6 (Manager of Neuro ICU/IMCU) was interviewed on 2/23/15 at approximately 1130 hours, and confirmed after a fall the patient's family/significant other is to be notified by staff of the fall. This was not done for patient #6, 8, and 10 as required by facility policy and procedure.