HospitalInspections.org

Based on medical record review, policy review, and interview, the facility does not ensure nursing staff implement and/or develop care plans for 3 of 5 (Patient #1, 6 and 7) related to falls precautions. for each patient. Failure to follow protocols places patients at risk of not receiving needed interventions for patient safety.
Findings include:
Review of nursing policy #304 "Fall Prevention Program" last revised 03/14 revealed all patients over 16 will be assessed for potential risk of falling on admission utilizing the Morse Fall Scale. Based on the score, either a low or high risk nursing care plan will be initiated. This policy does not include minimum and/or specific nursing interventions to be implemented for both low and high risk falls patients.
Review of the Nursing Admission History dated 09/01/14 at 09:00PM revealed Patient #1 was a high risk for falls with a Morse Fall Scale score of 70 (a score over 51 indicates implementation of high falls risk prevention interventions).
Review of the nurses notes dated from 09/02/14 at 07:00AM to 09/03/14 at 07:00PM indicate Patient #1 is at high risk for falls and no bed alarm is being utilized.
Review of nursing note dated 09/03/14 at 01:15PM revealed Patient #1 fell from his wheelchair and a Hoyer was used to place him back in bed. A Posey (bed) alarm was placed under Patient #1. Patient #1 sustained a right elbow tear, a right knee tear and hit his head. No evidence was found to indicate nursing staff implemented a high risk falls care plan and/or falls precautions until after the fall.
Interview on 12/12/16 at 09:40AM with Staff #6 revealed the falls risk screening is done on admission. For a score higher than 50, a patient is placed on a bed and chair alarm for safety. The patient receives yellow socks, a yellow blanket and a yellow leaf on the door indicating that they are a falls risk. A falls care plan is made out.
Review of policy # 304 "Falls Prevention Program" last revised 8/16 (revised after index case) reveals all patients over age 18 will be assessed for potential risk of falling on admission, change in condition or after a fall utilizing the Morse Fall Scale. Based on the score, the low or high risk nursing care plan will be initiated. This policy does not include minimum and/or specific nursing interventions to be implemented for either low and/or high risk scores.
Review of the medical record for Patient #6 revealed a nursing note dated 12/9/16 at 11:11 PM indicating a Morse Fall score assessment of " 55 " identifying a high risk for falls. No nursing care plan for high risk of falls was found in the medical record.
Review of the medical record for Patient #7 revealed a nursing notes dated 12/3/16 at 03:00 PM to 12/12/16 at 07:00PM indicating he was at high risk for falls, has a bed alarm on and requires a two person assist. However, no evidence was found to indicate a Morse Fall Scale assessment and/or a nursing care plan for high risk of falls were performed.
Interview on 12/12/16 at 11:00AM with Staff #4, Nurse Manager verified these findings.