HospitalInspections.org

Based on interview and record review the hospital failed to conduct a thorough post fall assessment for one of five sampled patients who had fallen (Patient 1). This failure resulted in a missed opportunity to accurately revise the patient's care plan to implement preventative approaches.

Findings:

Review of the Nurses Notes, dated 1/21/25, indicated at 1:05 p.m., Patient 1 was found sitting on the floor. The same note time 1:20 p.m. indicated Patient 1 stated he did not hit his head when he fell.

Review of Patient 1's X-ray (a digital image of the body) report, dated 1/21/25 sy 2:31 p.m., indciated Patient 1 had an injury of fractured tibia (upper part of the shinbone near the knee).

During an interview on 2/25/25 at 12:50 p.m. registered nurse (RN) A who was assigned to Patient 1 on the day of the fall stated Patient 1 was alert and oriented and the patient stated he was going to the bathroom when he fell. RN A stated Patient 1s bed alarm (device that sounds when a patient moves out of bed) was turned on and she did not remember if it alarmed.

Review of Patient 1's record did not contain an assessment indicating the circumstance and potential cause(s) of the fall, (i.e. patient trying to get out of bed, status of bed alarm).

The Fall Prevention policy, dated 08/2023, indicated charge nurses were to ensure the completion of the electronic medical record of post fall assessment. Staff were to conduct post fall huddle to include involving staff caring for the patient at the time of fall, patient and family whenever possible, and to utilize a spirit of inquiry to discover fall type and preventability.

During an interview on 2/25/25 at 1:20 p.m., RN B who reviewed the record stated she could not find the huddle or post fall assessment indicating the potential cause(s) of the fall.