HospitalInspections.org

Based on document review, observation, and interview, it was determine the Hospital failed to appropriately evaluate on an ongoing basis to ensure patients were cared for in accordance with accepted standards of nursing practice and hospital policy. Therefore, the Condition of Participation, 42 CFR 482.23, Nursing Services was not met.

Findings include:

1. The Hospital failed to ensure a registered nurse supervised and evaluated the nursing care for all patients by failing to assess/re-assess for fall risk and to provide fall interventions. See A-0395

A. Based on document review, observation, and interview, it was determined for 5 of 11 (Pt #1, Pt #3, Pt # 9, Pt # 10, and Pt #12) inpatient records reviewed for high fall risk, the Hospital failed to ensure a registered nurse supervised and evaluated the nursing care for all patients by failing to assess/re-assess for fall risk and to provide fall interventions.

Findings include:

1. On 7/05/23 the policy titled "Inpatient Fall Prevention and Management (revised May 2023)" was reviewed. The policy stated, "... 1) Assessment a) Patients are assessed for risk of fall by a nurse using a hospital approved assessment scale/tool at the time of admission, at least daily, upon transfer by the receiving unit, or with any change in the patient's condition.... b) Patients with a Morse Fall Risk Scale Score (greater than/equal to) 45... or with a recent history of falls are considered to be high fall risk.... 2) Interventions... b) High Fall Risk Patients... II. Fall prevention resources available at hospital affiliates may include: 1. Non-skid slippers/socks...3. Exterior room signage... 6. Bed and chair exit alarms... 6) Post Fall Patient Management... b. Special Considerations if Patient Hit Head or Unwitnessed Fall...ii. Observations: 1. Record vital signs and neurological assessment at least hourly for 4 hours. 2. Continue neurological assessments at least every 4 hours for the next 20 hours (for a total of 24 hours), then as ordered.

2. On 07/05/23 between 10:45 AM and 1:00 PM observational tours were conducted on 2E Medical, 2E Oncology, 3B Rehab, 3C Medical ICU, 3E IMC, 4B Medical/Surgical Unit, 4G Neurology, and 6B Short Stay units. The following was noted:

- 2E Oncology - Pt #3 was observed to be on fall precautions. Pt #3's door lacked signage of a high fall risk. Record review during the observation indicated, Pt #3 had a Morse Fall Risk Scale score of 70, indicating a high fall risk on 7/5/23 at 6:00 AM. An interview was conducted during the observation with the Nurse Manager (E #9). E #9 confirmed the door did not have fall risk signage and should have.

- 4G Neurology - Pt #10 was observed to be on fall precautions. The alarm for pt's #10's bed was observed to be turned off during the tour. The clinical record was reviewed on 7/6/23 and noted a Morse fall risk score of 45. During an interview with E#6 during the tour, it was confirmed the bed alarm was off.


3. On 07/06/23 between 8:30 AM and 9:30 AM observational tours were conducted on 2G Bariatric/Plastics, 2B Surgical and 5B. The following was noted:

- 2G Bariatric/Plastics - Pt #12 was sitting in a recliner. Pt #12 was wearing brown socks and there was no chair alarm in the chair. Interview and record review was conducted with RN (E# 8) during the observation. Pt #12 had a Morse Fall Risk Scale score of 50, indicating a high fall risk at 6:00 am on 7/6/23. E #8 reviewed the record and verbally agreed Pt #12 was a high fall risk and stated, "Patients who are a high fall risk are to have on red socks, utilize bed alarms and chair alarms. (Pt #12) should have red socks on and should have a chair alarm."

4. Pt #1 was admitted to the hospital on 03/16/23 with a diagnosis of Acute Renal Failure, Closed fracture of right clavicle, and Chronic leukemia. Pt #1's Morse Fall Risk Scale score upon admission was 55, indicating a high fall risk. On 3/19 at 7:00 PM, the Morse Fall Risk Scale score was 70. Pt #1's "Fall Event" record stated, "Patient found on the floor during hourly rounds. Patient was going to the bathroom and had unassisted fall. On assessment, patient was bleeding on the right elbow.... overnight last night patient toileted at 2000, 2100, 2200, 2300. Patient then asked for a urinal. PCT obtained for patient and admits to forgetting to set bed alarm. LPN rounding on patients at 0100 (1:00 AM) and found patient down on his right side in the bathroom doorway.... Initial key learning opportunities: When running Rauland report (call light notification system) noted that patient had used 'bath assist' button previously, leading me to believe the patient had previously been left alone in the bathroom...." Pt #1's record indicated neurological assessments were conducted at 1:00 AM, 5:00 AM and 5:00 PM. Pt #1's record lacked the required neurological assessments post fall.

-An interview was conducted to LPN (E #2). E #2 stated, "When I was doing my rounding, I found the patient on the floor. The PCT forgot to turn on the bed alarm. (Pt #1) should have had the bed alarm on as (Pt #1) was a high fall risk."

5. Pt. #9 was admitted to the hospital on 6/7/23 with a Diagnosis of Acute Obstructive Hydrocephalus. The clinical record was reviewed on 7/6/23. The record noted the pt was on fall precautions. The record lacked the Morse Fall Risk Scores from 0300 (3:00 AM) to 1400 (2:00 PM) on 6/18/23 and 7/2/23 from 0000 (12:00 AM) to 1300 (1:00 PM). During an interview with the Patient Safety Coordinator (E#7) on 7/6/23. E#7 verbally confirmed the lack of the Morse Fall Risk Scores.