HospitalInspections.org

Based on medical record review, document review, and interview, it was determined the facility staff failed to adhere to hospital policy and procedure following a patient's fall. Specifically, the facility failed to document; an injury assessment after discovering the patient fell, notification to the attending physician and the nursing leader, and the post fall assessment intervention.

Findings:

Review of hospital policy "Patient Fall Prevention" indicates, in part the following: Under the heading "Purpose - 4. Outline documentation requirements for nursing." Under the heading "Post-Fall Process - 1. Injury Assessment a. Prior to being moved, the patient will be immediately assessed for obvious injuries and to determine level of severity. Assessment will include: vital signs, neurological, musculoskeletal, circulatory, integumentary, psychological status, and pain... 2. Notifications of fall a. At a minimum, the Attending Physician, Nursing Leader, and patient's legal representative will be notified as soon as possible. b. All notifications will be documented in the EHR [Electronic Health Record]. 3. Reporting a. For each patient fall, the nurse will document in the Post Fall Assessment intervention within the EHR...". The policy was last revised and effective June 2023.

The review of medical record (MR) 1 revealed MR1 was admitted as an inpatient after presenting to the emergency department (ED) on February 4, 2025 for "weakness, dry cough, and vomiting". After a hold in the ED, MR1 was transferred to "4 MedSurg" on February 4, 2025 at approximately 11:00 PM.

On February 5, 2025 at 12:20 PM, a hospitalist's progress note indicated the patient fell overnight. A hip x-ray ordered by the provider (an image of the inside of the body created by electromagnetic waves) did not show a fracture. MR1 was experiencing pain in the ribcage so the provider ordered a x-ray of the ribs. The rib x-ray showed "new fractures of the right fifth through ninth ribs with evidence of displacement at the fractures sites. New pleural effusion and atelectasis".

The state agency (SA) was unable to locate evidence in MR1 that an injury assessment was performed immediately after discovering the patient had fell, notifications to the attending physician and the nursing leader were completed, and the post fall assessment intervention was completed.

During a telephone interview on March 11, 2025 at 9:07 AM, employee (EMP) 9 acknowledged they were "not aware" of the "computer part", but now they know where to add the post-fall assessment intervention in (EHR). EMP9 confirmed that the physician and charge nurse were notified "right away", but acknowledged they were not aware to add a nursing note documenting this information.

The SA asked EMP1 to review MR1 to verify that there was no documentation of an injury assessment, notification to attending physician and nursing leader, and of the post fall assessment intervention. EMP1 confirmed on March 11, 2025 at approximately 1:00 PM that there was no documentation of the three requirements.