HospitalInspections.org

A. Based on review of medical records, documents, it was determined the nursing staff failed to follow hospital policy relative to patients who have been assessed to be at increased risk for a fall for two (2) of ten (10) patients reviewed and observed (patients #5 and #8). This has the potential to create an environment of care in which falls occur that may have been preventable. Findings include:

1. Review of the policy "Patients at Risk for Falls", last reviewed 4/2007, revealed the policy states "If the patient is at risk for falls...a purple band will be placed on the patient's wrist. A purple star will be placed on the door to signify to all who enter that the patient is a high risk for falling...Keep the call bell, telephone, TV control, bed control block (if the patient is on an electric bed), and personal items within sight and easy reach of the patient."

2. Observations of patients #5 and #8 revealed the patients' call bell buttons were not within easy reach as policy directs.

3. Patient #5 was observed on the second floor nursing unit on 1/26/10 at 11:30 a.m. The patient had a "falling star" sign near the bed and the patient was wearing a purple arm band to indicate she was high risk for a fall. The patient was observed to be sitting up in a chair. The patient stated her call bell button was hanging on the side of the bed to her right. When the patient was asked to obtain the call bell button, she was unable to stretch her right arm completely and was unable to pick up the call bell. Review of the medical record for the patient revealed the patient was being treated for a fractured right humerus. The Nurse Manager of the second floor was present during the time of the observations.

4. Patient #8 was observed on the third floor nursing unit on 1/27/10 at 10:30 a.m. Review of the medical record revealed the patient had just been admitted and had arrived to the nursing unit at 6:55 a.m. on 1/27/10. The patient was admitted for a fractured left proximal humerus. The record indicated the patient had fallen at home. The Emergency Department nurse had assessed the patient to be at risk for a fall. When the patient was observed at 10:30 a.m., it was noted the call bell button was hanging over the rail on the left side of the patient. When asked if she knew how to call for a nurse, the patient stated that no one had explained that to her. When asked if she could reach the button to call, the patient stated she could not move her fractured arm over to pick up the button. The information was reviewed with the Nurse Manager of the third floor nursing unit in the afternoon on 1/27/10.



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B. Based on document review, medical record review and staff interview the hospital failed to ensure the nurse adequately establishes the patient's fall precaution needs, per hospital policy, in one (1) of two (2) closed records (Patient #1) reviewed. This has the potential to negatively impact all patient care by not providing adequate interventions to reduce the risk of falls and patient harm. Findings include:

1. Beckley Appalachian Regional Hospital (BARH) policy Fall Prevention F-II-08, effective 10/21/05, states in part "...To comprehensively assess all inpatients utilizing the Morse Fall Scale (MFS) to assess their level of risk for falls and implement fall prevention/injury reduction interventions as appropriate...Fall prevention/injury reduction interventions will be utilized for all patients; patients identified at risk will have additional interventions implemented as appropriate..."

2. Review of the medical record for Patient #1 revealed on 12/12/09 at 1030 the nurse documented assessment of the patient's fall risk as being High Risk. However, documented evidence shows the patient was only placed on Low Fall Risk Precautions. Further review of the medical record revealed a nurse's note dated 12/12/09 at 1150 stating in part "Patient in 301 and was in 303 doing a blood sugar. Overheard a bang in the room and something hit the wall. When entered room found patient lying in floor on her back between bed and wall at foot of bed. Bleeding noted from back of head 1" in size. Pressure held to site...Hematoma noted left side mid back..." Only after the patient's fall is there documented evidence of any High Risk Interventions being implemented.

3. During an interview in the afternoon of 1/27/10 the Unit Manager agreed with the above findings.