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Based on record review and interview the facility failed to provide appropriate nursing care to meet the needs of 4 of 5 (#1, #2, #3, #5) patients who were assessed for fall risk and were found on the floor.

The findings included:

Review of the current facility policy for Fall Prevention revealed that all patients would be assessed for fall risk on admission. The patient is identified at high risk for falls if the patient has one or more of the following elements: periodic confusion, fall history, cane, walker or crutches, decreased muscle coordination, incontinence or urinary frequency, IV pole, unsteady gait. Each nurse is expected to use his/her judgment when assessing a patient for risk of falls. The nurse may place the patient on fall precautions regardless of the fall risk score.

Review of the clinical record of patient #1 revealed that the patient was admitted to the facility on 2/23/10 with generalized lymphadenopathy and mechanical heart valve occlusion. The patient used a fentanyl patch for pain and Demerol IV. The care plan was created with fall risk on 2/23/10, impaired musculoskeletal impairment on 2/27/10, impaired genitor-urinary function on 2/28/10, surgical site skin impairment on 2/28/10, impaired cardiac function on 3/5/10, impaired respiratory function on 3/5/10, impaired neurological function on 3/5/10, and impaired tissue perfusion on 3/6/10. The risk for falls care plan that was created on 2/23/10 included having the call bell near the patient and hourly supervision. The patient fell on 2/27/10 and the care plan was updated to include bed rest with a bed alarm. Before the fall the patient had the fentanyl patch on, had received Demerol by IV, Xanax and Percocet by mouth, decreased muscle coordination, incontinence or urinary frequency, and dementia.

Review of the clinical record of patient #2 revealed that the patient was admitted to the facility on 2/24/10 with cellulitis of the right foot. The patient's history included dementia. The care plan was created and included identification of and interventions for risk for falls on 2/24/10, skin impairment on 2/24/10, impaired tissue perfusion on 2/24/10, independence of older adult on 2/24/10, impaired respiratory function on 2/25/10, impaired neurological function on 2/25/10, and impaired musculoskeletal impairment on 3/2/10. The risk for falls care plan that was created on 2/24/10 included having the call bell near the patient, bed alarm and hourly supervision. The patient fell on 3/2/10 and the care plan was not updated with any additional safety measures.

Review of the clinical record of patient #3 revealed that the patient was admitted to the facility on 4/13/10 with acute respiratory failure. The patient's history included chronic pain syndrome. The care plan was created and included identification of and interventions for impaired respiratory function on 4/13/10, pain on 4/13/10, risk for deep vein thrombosis on 4/13/10, independence of older adult on 4/13/10, impaired tissue perfusion on 4/13/10, impaired neurological function on 4/13/10, impaired musculoskeletal impairment on 4/13/10 and risk for falls on 4/15/10. The risk for falls care plan was created on 4/15/10 after the patient fell. The care plan was updated with a low bed and alarms. Before the fall the patient had received Morphine IV every 3 hours. Interview with the Nurse Manager for ICU on 5/19/10 at 1:30 pm revealed that patient #3 had 4 to 5 family members in the area. The Nurse Manager met with the family before the extubation and fall. There were no indications of problems except for the pain medication that the patient required around the clock. The tube was removed and the family left. Interview on 5/19/10 at 1:45 pm with the staff nurse who cared for patient #3 on the day of the fall revealed that the patient had no bruising on the body before the fall. After the patient was extubated, the patient in the next room was coding and required attention. The family for patient #3 had just left and the staff heard a crash and found the patient on the floor. After the fall the patient was moved to a different room, closer to the station and placed in a low bed. The patient had made no complaints about any pain from the fall.

Review of the clinical record of patient #5 revealed that the patient was admitted to the facility on 4/14/10 with sepsis and acute renal failure. The patient's history included dementia. The care plan was created and included identification of and interventions for impaired respiratory function on 4/14/10, pain on 4/14/10, fall risk on 4/15/10, independence of older adult on 4/15/10, risk for deep vein thrombosis on 4/15/10, impaired musculoskeletal impairment on 4/15/10, and impaired neurological function on 4/15/10. The risk for falls care plan was created on 4/15/10 with bed alarms and a low bed. The patient fell on 4/17/10 and the care plan was not updated with any additional safety measures.

Based on record review and interview the facility failed to create and implement an appropriate care plan for 4 of 5 (#1, #2, #3, #5) patients who fell in the facility.

The findings included:

Review of the current facility policy for Fall Prevention revealed that all patients would be assessed for fall risk on admission. The patient is identified at high risk for falls if the patient has one or more of the following elements: periodic confusion, fall history, cane, walker or crutches, decreased muscle coordination, incontinence or urinary frequency, IV pole, unsteady gait. Each nurse is expected to use his/her judgment when assessing a patient for risk of falls. The nurse may place the patient on fall precautions regardless of the fall risk score.

Review of the clinical record of patient #1 revealed that the patient was admitted to the facility on 2/23/10 with generalized lymphadenopathy and mechanical heart valve occlusion. The patient used a fentanyl patch for pain and Demerol IV. The care plan was created with fall risk on 2/23/10, impaired musculoskeletal impairment on 2/27/10, impaired genitor-urinary function on 2/28/10, surgical site skin impairment on 2/28/10, impaired cardiac function on 3/5/10, impaired respiratory function on 3/5/10, impaired neurological function on 3/5/10, and impaired tissue perfusion on 3/6/10. The risk for falls care plan that was created on 2/23/10 included having the call bell near the patient and hourly supervision. The patient fell on 2/27/10 and the care plan was updated to include bed rest with a bed alarm. Before the fall the patient had the fentanyl patch on, had received Demerol by IV, Xanax and Percocet by mouth, decreased muscle coordination, incontinence or urinary frequency, and dementia.

Review of the clinical record of patient #2 revealed that the patient was admitted to the facility on 2/24/10 with cellulitis of the right foot. The patient's history included dementia. The care plan was created and included identification of and interventions for risk for falls on 2/24/10, skin impairment on 2/24/10, impaired tissue perfusion on 2/24/10, independence of older adult on 2/24/10, impaired respiratory function on 2/25/10, impaired neurological function on 2/25/10, and impaired musculoskeletal impairment on 3/2/10. The risk for falls care plan that was created on 2/24/10 included having the call bell near the patient, bed alarm and hourly supervision. The patient fell on 3/2/10 and the care plan was not updated with any additional safety measures.

Review of the clinical record of patient #3 revealed that the patient was admitted to the facility on 4/13/10 with acute respiratory failure. The patient's history included chronic pain syndrome. The care plan was created and included identification of and interventions for impaired respiratory function on 4/13/10, pain on 4/13/10, risk for deep vein thrombosis on 4/13/10, independence of older adult on 4/13/10, impaired tissue perfusion on 4/13/10, impaired neurological function on 4/13/10, impaired musculoskeletal impairment on 4/13/10 and risk for falls on 4/15/10. The risk for falls care plan was created on 4/15/10 after the patient fell. The care plan was updated with a low bed and alarms. Before the fall the patient had received Morphine IV every 3 hours. Interview with the Nurse Manager for ICU on 5/19/10 at 1:30 pm revealed that patient #3 had 4 to 5 family members in the area. The Nurse Manager met with the family before the extubation and fall. There were no indications of problems except for the pain medication that the patient required around the clock. The tube was removed and the family left. Interview on 5/19/10 at 1:45 pm with the staff nurse who cared for patient #3 on the day of the fall revealed that the patient had no bruising on the body before the fall. After the patient was extubated, the patient in the next room was coding and required attention. The family for patient #3 had just left and the staff heard a crash and found the patient on the floor. After the fall the patient was moved to a different room, closer to the station and placed in a low bed. The patient had made no complaints about any pain from the fall.

Review of the clinical record of patient #5 revealed that the patient was admitted to the facility on 4/14/10 with sepsis and acute renal failure. The patient's history included dementia. The care plan was created and included identification of and interventions for impaired respiratory function on 4/14/10, pain on 4/14/10, fall risk on 4/15/10, independence of older adult on 4/15/10, risk for deep vein thrombosis on 4/15/10, impaired musculoskeletal impairment on 4/15/10, and impaired neurological function on 4/15/10. The risk for falls care plan was created on 4/15/10 with bed alarms and a low bed. The patient fell on 4/17/10 and the care plan was not updated with any additional safety measures.