HospitalInspections.org

Based on records reviewed and interviews the Hospital failed for three (Patients #1, #Patient 6 & Patient #7) patients of ten sampled patients to implement opportunities for improvement regarding patient falls after Patient #1's, Patient #6's and Patient #7's adverse events.

The Hospital failed to implement opportunities for improvement regarding:

1.) Physician evaluation documentation after a patient fall,

2.) Clear staff instructions of Hospital expectations regarding Physician (or Licensed Independent Provider) notification to evaluate a patient after a fall and

3.) Coordinated instructions between nursing services and transport services for monitoring patients at risk for falls when the patient is off the patient care unit for testing.


Findings included:

The document titled, Quality Improvement Plan, dated 2019, indicated the Hospital had a process for improvement. The Quality Improvement Plan indicated the Hospital monitored performance by collecting data that allowed the Hospital to decide on improvements.

The document titled, Falls Review Process, undated, indicated that a staff nurse, nurse leader or Department Manager was responsible to complete a review of the event, talking to the patient witnesses or staff members who were in proximity and had knowledge of the event.

The Surveyor interviewed the Quality Director at 1:30 P.M. on 7/11/19. The Quality Director said that the Falls Committee reviewed falls; however, the Falls Committee had not met after 4/2018.

The Hospital policy titled, Fall Risk Assessment, dated 9/28/18, indicated that the Hospital called a Rapid Response (emergency response personnel) when a patient fell and struck the head. The Fall Risk Assessment policy did not indicate clear instructions for when staff were expected to contact a Physician (or Licensed Independent Provider) to evaluate a patient after a fall. The Hospital Fall Risk Assessment policy did not indicate instructions for monitoring patients at risk for falls when off the patient care unit for testing.

The Hospital policy titled, Observer, dated 5/31/18, indicated the Hospital implemented either a constant observer (person) or a visual monitor (device) to monitor patients evaluated to have a high risk for fall. The policy did not indicate instructions for monitoring Patients at risk for falls when off the patient care unit for testing.

The Hospital Policy titled, Central Transport Services Stretcher Procedure, dated 7/16/15, indicated that floor (patient care unit) staff accompanied patients on fall precautions (at risk for fall).

Regarding Patient #1's fall:

The History & Physical, dated 10/11/18, indicated that Patient #1 was admitted from a cardiac clinic for a syncopal (fainting) episode and a history of falls.

A Nurse's Note, dated at 10:04 P.M. on 10/11/18, indicated the nurse assessed Patient #1 on admission to the Hospital to be at a high risk of falling.

A Nurse's Note, dated at 9:42 P.M. on 10/12/18, indicated Patient #1 fell from a stretcher today at approximately 2:30 P.M. while at cardiology.

A.) The Surveyor interviewed the Senior Transport Manager at 11:15 A.M. on 7/11/19. The Senior Transport Manager said the nursing staff on the patient care unit documented the patient's fall risk on a document called a Ticket to Ride (a document of communication between patient care unit nursing staff and transport personal). The Senior Transport Manager said the Transport Staff use the Ticket to Ride for the patients fall status.

The Hospital provided no documentation that Patient #1's fall risk was appropriately communicated from the nursing staff to the Transport Staff on a Ticket to Ride.


B.) Medical Record review indicated no documentation by a physician that evaluated Patient #1 in cardiology after Patient #1's fall. Medical Record review indicated a physician note at 11:53 A.M. on 10/13/18 regarding Patient #1's fall.

The Surveyor interviewed the Quality Director at 7:30 A.M. on 7/12/19. The Quality Director said a physician did not document an evaluation of Patient #1 after the fall in cardiology in Patient #1's medical record.

Regarding Patient #6's fall:

A Hospital Report, dated 3/15/18, indicated Patient #6 was found dangling out of bed in between the bed siderails, with the torso (chest) out of the bed and head noted on the floor. The Medical Record indicated no documentation that an Emergency Response Team was notified.

The Resident Progress Note, dated at 7:44 P.M. on 3/15/19, approximately 12 hours after the fall, indicated a Computerized Tomography (CT) scan of the head and spine showed no acute findings.

Medical Record Review indicated no nursing flow sheet documentation regarding Patient #6's fall.

Regarding Patient #7's fall:

A Hospital Report, dated 6/22/19, indicated Patient #7 had a fall.

A Nurse's Note, dated at 11:25 A.M. on 6/22/19, indicated Patient #7 at 11:19 A.M. had a fall.

Medical Record Review indicated no Provider documentation on the day of the fall of an evaluation after Patient #7's fall on 6/22/19.