HospitalInspections.org

Based on patient medical record review, facility policy and procedure review and interview, the nursing supervisor failed to ensure that the policy related to fall prevention protocol was implemented for 1 of 4 patients who fell after admission (Pt. N1).

Findings:
1. At 12:35 PM on 7/26/10, review of the policy and procedure "Care of the Medical Surgical Patient", with Attachments A and B being "Fall Prevention Protocol" and "Purposeful Rounding Protocol", indicated:
a. in Attachment A, it read in the section titled "Level 1 Strategies:", All Patients--Orient patient to call light, bathroom location...Level 2 Strategies: All Level 1 Strategies Plus: Place yellow "Fall Risk" wristband on patient...Activate bed exit alert...Level 3 Strategies---All Level 1 and Level 2 Strategies Plus: If patient has cognitive impairment:...Use personal alarm in addition to bed exit alert..."

2. At 1:00 PM on 7/26/10, review of patient medical records indicated:
a. on admission, the nursing assessment done at 10:42 AM on 6/10/10 indicated that patient N1 was a level 3 risk for falls (high risk) and in the section related to "Cognitive Impairment", nursing noted: "yes"
b. nursing documented that the yellow wristband designating the patient as a high risk for falls was placed on patient N1 on admission
c. patient N1 reported to facility staff at 6:00 AM on 6/11/10 that they had fallen in the bathroom--LPN (licensed practice nurse) noted an abrasion on the patient's back and alerted the RN (registered nurse)

3. Interview with staff member NB at 11:40 AM, 1:30 PM and 2:30 PM on 7/26/10 indicated:
a. a bed alarm was not activated for pt. N1 as family members were acting as "sitters" for the patient
b. when the family member left the patient's room for coffee/breakfast on the morning of 6/11/10, the patient got up on their own and fell in the bathroom
c. it is this staff member's interpretation of the policy that nursing can determine which of the "guidelines" listed in the policy, may be implemented for a particular patient