HospitalInspections.org

Based on interview and review of medical chart and polices, the facility failed to ensure a reassessment of a fall was assessed and documented for 1 of 9 patients (Patient #9) reviewed for fall precautions.

Findings:

On 3/16/2017, a review of medical chart for Patient #9 showed that on 2/6/2017 at 3:46 AM, Patient #9 was observed on the floor next to the bed sitting on a bed pad. Patient #9 stated she did not know why she was on the floor. Further review of the medical chart showed on 2/06/2017 for 7:00 PM to 7:00 AM shift that there had been no reassessment on the medical chart after the fall for Patient #9.

During an interview on 3/16/2017 at 4:30 PM, The Director of Neuro/Medical/Surgical Unit stated that there should be a nurse's note about the fall and reassessment of the patient in the chart for Patient #9.

During an interview on 3/16/17 at 5:22 PM, the Interim Director of Quality stated there should be a note on the chart describing the fall with a reassessment done for Patient #9.

A review of the facility's policy titled, "Interdisciplinary Patient Assessment/Reassessment Plan," revised 12/5/2016, showed under nursing service, reassessments are performed more frequently, as warranted by the patient's condition and/or change in care/level of service. Reassessment is performed every shift or more frequently as indicated by the patient condition. Patients are re-assessed at a minimum of every 12 hours.

Review of facility's policy titled, "Fall Prevention Program," revised 1/27/2017, showed a yellow magnet would be put on the door to patient's room. A subsequent fall risk assessment is completed with each reassessment and any changes in level of care. Interventions include education for both patient/family, and observation of patient during rounding.