HospitalInspections.org

Based on medical record review, interviews, review of the Patient Safety Event Report, Post Fall Assessment Form and the Falls Prevention and Resources Policy and Procedure and information obtained form the Food and Drug Administration Website, the Governing Body failed to ensure the attending physician, pharmacist and staff followed the hospital's Policy And Procedure related to Falls Prevention including post fall care of Patient Identifier (PI) # 1, a patient identified as a high fall risk, who fell on 2/26/14 and sustained an injury to the head. As a result, the CT (Computed Axial Tomography) scan of the head (for a patient on blood thinners) was not done immediately after PI # 1's fall. This deficient practice affected PI # 1, one of ten sampled patients, and has the potential to affect all patients at risk for falls.

Findings Include:

Medical Record Review Includes:

Hospital Course: PI # 1 was evaluated in the Emergency Department on 1/31/14 for hypotension, was treated with IV (intravenous) fluids and admitted. On 1/31/14 PI # 1 was transferred to the Geriatric Psychiatric Unit due to dementia and associated agitation. Due to consistent refusal of food and medications, PI # 1 became poorly responsive and was transferred to Medical Intensive Care on 2/15/14. PI # 1's sodium was elevated at 185 and a urinary tract infection was present. A PEG (Percutaneous Endoscopic Gastrostomy) tube was placed in 2/19/14 and tube feedings were initiated in addition to a regular diet. PI # 1 was discharged on 3/2/14 in good condition.


According to the Nursing Note dated 2/16/2014 at 18:00, "Pt. (patient) fell on the floor, found face down on floor, assisted up to bed, head to toe assessment done, has knot on right upper forehead, does not complain of pain."

Nursing Note dated 2/26/2014 at 18:30 revealed, "(Dr. /Last Name of Physician) paged still no call back, repaged."

According to the Nursing Note dated 2/26/2014 at 19:00, "Paged (Dr./ last name of Physician) again no call back."

"Paged (Dr./ Name of Physician) again no call back," documented in the Nursing Note dated 2/26/2014 at 19:50.

Nursing Note dated 2/26/2014 at 20:30 revealed, "Paged (Dr. /Last Name of Physician) again, and notified family that patient (PI # 1) fell."


Interviews:

During an interview on 5/14/14 at 10:15, the Attending Physician/ Employee Identifier (EI) # 1 said she examined the patient the day after the fall. The CT (Computed Tomography) of the head showed no acute changes. PI # 1's Haldol was increased because it helps to decrease agitated dementia. When asked if she spoke with PI # 1's family EI # 1 said, "I'm sure I talked about the CT, but I didn't write it down."


During an interview on 5/14/14 at 11:45, the Registered Nurse (RN) / EI # 2, assigned to care for PI # 1 on 2/26/14, said the patient was confused and unable to ambulate independently. PI # 1 had a bed alarm and would start trying to get out of bed in the late afternoon. "( PI # 1) kept climbing out of bed. We reset the alarm. Probably we forgot to turn it back on." The bed alarm did not sound when the patient fell. According to EI # 2, a Patient Care Assistant (PCA) noticed the patient was on the floor and, "Got me right away." The RN said three side rails were up and the patient, "Probably crawled through the rail." The RN and the PCA got the patient back in bed. The RN said he did a "quick" assessment and noticed a red, minimally swollen area on the right side of PI # 1's forehead. The RN said he spoke with the physician sometime after 19:00 and a CT of the head was ordered.


During an interview on 5/15/14 at 11:40, the Pharmacist / EI # 3 stated the pharmacist does not review a patient's medication specifically for falls unless consulted by a nurse or physician. There was no pharmacy consultation (related to medications and fall risk) done for PI # 1 on admission or after the patient's fall on 2/26/14.


During an interview on 5/15/14 at 14:05, the Director of the 4th Floor Nursing Unit / EI # 5 was asked about actions taken after PI # 1's fall (specifically related to the documentation about four side rails in the up position and the alarm not sounding when the fall occurred on 2/26/14). The Director said she reviewed PI # 1's chart and there was no order for side rails. Regarding the multiple attempts by the RN to notify the attending physician about PI # 1's fall, EI # 5 said she spoke with the RN assigned to PI # 1 and advised the RN of options to contact the house supervisor or the Medical Director when there is a delayed response from a physician concerning a patient. (The RN began attempting to contact the attending physician at 18:30, but there was no response from the physician until 21:13 as documented on the Post Fall Assessment Form (2 hours and 43 minutes after PI # 1's fall).


A review of the Patient Safety Event Report dated 2/26/2014 at 21:20 revealed:

"Nature of Event: Unobserved fall.

Specify: Found on Floor...

Where did the patient fall from? Bed.

How many side rails were in use at the time of the event? 4.

For what use? Fall Prevention...

Was any sensor device in use prior to fall? Yes.

Fall risk assessment - Time elapsed: > (greater than) 0 to 12 hours.

Documented fall risk assessment: Morse Risk Score: 90.

Was the patient determined to be at risk for fall? Yes...

At the time of the fall was the patient on medication known to increase the risk for a fall? Yes.

Drug Name: Haldol 5 milligrams.

Enter a brief description of the event: Patient was found face down by... bed by (first name of PCA - Patient Care Assistant), I was called into the room and we assisted...up to bed. Bed alarm was 'turn off' we both left the alarm on when we last left the room. A head to toe assessment was completed there were no changes from previous assessment except for a contusion on the top right eye brow/forehead. The family was later notified and asked to come and stay with the patient because...has a history of climbing out of the bed...

When did this occur? 2/26/2014 18:00... Location: Patient Room...

Diagnostic Tests performed: CT (Computed Tomography) of head..."


A review of the Post Fall Assessment Form revealed PI # 1 fell on 2/26/2014 at 1800:

"Morse Fall Scale Risk Screening Score at time of Fall: 90 (per scale a score of greater than 45 is a high risk score). On Admission: 95...

High Risk Score: > (greater than) 45

Was any injury sustained? Yes. If yes describe injury and action taken: Contusion right forehead.

Was patient on blood thinners? Yes. If yes, and patient sustained head
injury notify physician immediately to obtain a 'Cat' (Computed Axial Tomography) Scan.

Neuro (neurological) checks should be completed every 15 minutes x 4, every 30 min (minutes) x 2; every 1 hour x 4; then every 4 hours x 48 hours unless ordered otherwise by physician.

Medications Management: Please list HIGH RISK and 1st DOSE Meds (Medications) within 12 hours of fall per policy.

1. Aspirin 81 milligrams (mg.) at 10:00. (Nonsteroidal anti-inflammatory drug that has an antiplatelet effect).
2. Lovenox 30 mg. at 1856. (Anticoagulant - blood thinner).
3. Haldol 5 mg. QID (four times daily). (Antipsychotic - can cause dizziness)...

Fall Occurred While: Not witnessed.

Fall was: Anticipated...

What position was the patient found immediately post fall: face down, prone.

Did the patient initiate the call light prior to falling? No.

Patient's Mental Status: Confused/Disoriented...

Patient's Behavior: Impulsive...

Was there an order for postural supports/restraints? No.

a. Was support/restraint in place? Yes.

b. Were four side rails up at the time of fall: Yes...

Was there a warning sign prior to the fall? Yes. Patient 'has try' climbing out of bed.

MD (Medical Doctor) notification: Yes. Date: 2/26/14. Time: 21:13.

Orders given and test results: CT of head ordered..."


On 2/26/14 at 18:00 only one set of vital signs and one neurological check : AO (alert and oriented) x 1 is documented on the Post Fall Assessment Pulse: 88, Respirations: 16, Blood Pressure: 107/54.


"Policy and Procedure Directive
Subject: Falls Prevention and Resources
Date: 5/05 Revised: 6/13

I. Scope: This policy applies to (name of hospital), its employees, medical staff...regardless of service location or category of patient...

II. Purpose:

A. Establish guidelines for mitigating the risk of patient falls.
B. Establishing a framework for assessing risk factors for...falls, implementing intervention for reducing the risk for falling, and protecting patients from injury if a fall should occur.
C. Establish guidelines for the prevention of ...falls through the diligent assessment, ongoing communication and appropriate proactive action.
D. Establish guidelines to define action in the event of a fall and complete the required follow-up assessments and documentation.
E. Establish guidelines for staff to retain responsibility for patient safety at all times, even if family members are present.

III. Definitions:

...E. Factors which may increase risk for falls include:

...2. Age...

5. Use of restraints...

8. Difficulty understanding/retaining instructions...

14. Taking high risk medications...


F. Secondary diagnoses which may increase risk for falls include, but are not limited to the following:

...4. Bowel bladder incontinence/frequent toileting...

8. Dementia/Alzheimer's


IV. Policy:
...This hospital will take steps to reduce the number and severity of patient falls by doing the following:

A... Complete frequent vital signs on falls with injury... Every 15 minutes x 4, every 30 minutes x 2, every hour x 2, then every 4 hours x 48 hours...


V. Procedure:

A. Initial Falls Risk Assessment

1. Upon entry into the hospital system...a registered nurse (RN) should...complete the Morse Fall Scale Risk Screening Tool...as part of the patient's admission record...

B. Fall Risk Assessments:

1. Morse Scale Assessment:

...c. Patients who score 45 and above are considered 'High Risk' for falls.

d. Patients that were admitted with any reason related to a fall...will be assigned an 'E.' The patient assigned an 'E' rating will be considered an EXTREME fall risk for the duration of that hospitalization...


h...Table A Medication Classifications provides some of the highest risk medication classes that place the patient at highest risk for falls." (List includes psychotropics (Haldol) and Blood Thinners (Lovenox and Aspirin)


C. Medication Classification Assessment:

4. As part of the initial assessment, a pharmacist will review medications
and supplements to assess for medications that increase risk for falls.... In addition, Pharmacy will intervene by completing a 'Pharmacy Medication Assessment for Fall Risk' and using the 'Pharmacy Fall Assessment Drug Therapy Recommendation' as a guideline...


E. Mandatory Fall Alert Interventions:

1. All patients identified as at risk for falls should have interventions implemented to alert other healthcare workers....of the fall potential.

2. Minimally, all of the following measures will be implemented at all times:

a. For high/extreme risk, a yellow armband must be place on the wrist and yellow or no-slip/skid socks be applied...

f. Make sure the bed is secured and locked in low position...and 2-3 side rails up...


I. Post-Fall Management:

1. Assess for injury...

4. Obtain vital signs, a physical assessment and neuro (neurological) checks after every fall:

a. Every fifteen minutes x 4, every 30 minutes x 2, every 1 hour x 2, every 2 hours x 2, then every 4 hours x 48 hours...


The hospital failed to ensure:

- PI # 1's bed alarm was on at the time of the fall;

- two to three side rails were in the up position, not four as documented (Potential risks of side rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress, more serious injuries from falls when patients climb over rails, feeling isolated or unnecessarily restricted,etc. according to the FDA (Food and Drug Administration, 10/2000 - last updated 4/24/14);

- the attending physician responded/ returned call to the RN in a reasonable amount of time after the PI # 1 fell;

- the CT scan was done immediately after PI # 1's fall (per instructions on Post Fall Assessment Form)

- the patient's vital signs and neurological checks were done every fifteen minutes x 4, every 30 minutes x 2, every 1 hour x 2, every 2 hours x 2, then every 4 hours x 48 hours post fall;

- Pharmacist reviewed PI # 1's medications for risks associated with falls and

- PI # 1's fall was thoroughly investigated including interview of all involved parties post fall.

Based on medical record review, interviews, care plan review, review of the Patient Safety Event Report, Post Fall Assessment Form and the Falls Prevention policy and procedure, the hospital failed to ensure nursing staff maintained and modified a current care plan related to falls for Patient Identifier (PI) # 1, a patient identified as a high fall risk, who fell on 2/26/14 and sustained an injury to the head. This deficient practice affected PI # 1, one of ten sampled patients, and has the potential to affect all patients identified as a fall risk.

Findings Include:

Medical Record Review Includes:

Hospital Course: PI # 1 was originally evaluated in the Emergency Department on 1/31/14 for hypotension, was treated with IV (intravenous fluids) and admitted. On 1/31/14 PI # 1 was transferred to the Geriatric Psychiatric Unit due to dementia and associated agitation. Due to consistent refusal of food and medications, PI # 1 became poorly responsive and was transferred to Medical Intensive Care on 2/15/14. PI # 1's sodium was elevated at 185 and a urinary tract infection was present. A PEG (Percutaneous Endoscopic Gastrostomy) tube was placed in 2/19/14 and tube feedings were initiated in addition to a regular diet. PI # 1 was discharged on 3/2/14 in good condition.


According to the Nursing Note dated 2/16/2014 at 18:00, "Pt. (patient) fell on the floor, found face down on floor, assisted up to bed, head to toe assessment done, has knot on right upper forehead, does not complain of pain."

Nursing Note dated 2/26/2014 at 18:30 revealed, "(Dr. /Last Name of Physician) paged still no call back, repaged."

According to the Nursing Note dated 2/26/2014 at 19:00, "Paged (Dr./ last name of Physician) again no call back."

"Paged (Dr./ Name of Physician) again no call back," documented in the Nursing Note dated 2/26/2014 at 19:50.

Nursing Note dated 2/26/2014 at 20:30 revealed, "Paged (Dr. /Last Name of Physician) again, and notified family that patient (PI # 1) fell."


Interviews:

During an interview on 5/14/14 at 11:45, the Registered Nurse (RN) / EI # 2, assigned to care for PI # 1 on 2/26/14, said the patient was confused and unable to ambulate independently. PI # 1 had a bed alarm and would start trying to get out of bed in the late afternoon. " (PI # 1) kept climbing out of bed. We reset the alarm. Probably we forgot to turn it back on." The bed alarm did not sound when the patient fell. According to EI # 2, a Patient Care Assistant (PCA) noticed the patient was on the floor and, "Got me right away." The RN said three side rails were up and the patient, "Probably crawled through the rail." The RN and the PCA got the patient back in bed. The RN said he did a "quick" assessment and noticed a red, minimally swollen area on the right side of PI # 1's forehead. The RN said he spoke with the physician sometime after 19:00 and a CT of the head was ordered.

A review of the Patient Safety Event Report dated 2/26/2014 at 21:20 revealed:

"Nature of Event: "Unobserved fall.

Specify: Found on Floor...

Where did the patient fall from? Bed

How many side rails were in use at the time of the event? 4

For what use? Fall Prevention...

Was any sensor device in use prior to fall? Yes

Fall risk assessment - Time elapsed: > (greater than) 0 to 12 hours

Documented fall risk assessment: Morse Risk Score: 90

Was the patient determined to be at risk for fall? Yes...

At the time of the fall was the patient on medication known to increase the risk for a fall? Yes

Drug Name: Haldol 5 milligrams

Enter a brief description of the event: Patient was found face down by... bed by (first name of PCA - Patient Care Assistant), I was called into the room and we assisted...up to bed. Bed alarm was turn off we both left the alarm on when we last left the room. A head to toe assessment was completed there were no changes from previous assessment except for a contusion on the top right eye brow/forehead. The family was later notified and asked to come and stay with the patient because...has a history of climbing out of the bed...

When did this occur? 2/26/2014 18:00

...Location: Patient Room...

Diagnostic Tests performed: CT (Computed Tomography) of head..."


A review of the Post Fall Assessment Form revealed PI # 1 fell on 2/26/2014 at 1800:

"Morse Fall Scale Risk Screening Score at time of Fall: 90 (per Morse scale a score of greater than 45 is high risk...

Was any injury sustained? Contusion Right forehead

Was patient on blood thinners? Yes.

If yes, and patient sustained head
injury notify physician immediately to obtain a 'Cat' (Computed Axial Tomography) Scan.

Neuro (neurological) checks should be completed every 15 minutes x 4, every 30 min (minutes) x 2; every 1 hour x 4; then every 4 hours x 48 hours unless ordered otherwise by physician.

Please list HIGH RISK and 1st DOSE Meds (Medications) within 12 hours of fall per policy:

1. Aspirin 81 milligrams (mg.) at 10:00. (Nonsteriodal anti-inflammatory drug that has an antiplatelet effect).

2. Lovenox 30 mg. at 1856. (Anticoagulant - blood thinner).

3. Haldol 5 mg. QID (four times daily). (Antipsychotic - can cause dizziness)...

Fall Occurred While: Not witnessed.

Fall was: Anticipated...

Did the patient initiate the call light prior to falling? No....

g. If bed was equipped with alarm, was it on? No.

Patient's Mental Status: Confused/Disoriented

Patient's Behavior: Impulsive...

Was there an order for postural supports/restraints? No

a. Was support/restraint in place? Yes

b. Were four side rails up at the time of fall: Yes...

Was there a warning sign prior to the fall? Yes. Patient 'has try' climbing out of bed.

MD (Medical Doctor) notification: Yes Time: 21:13

Orders given and test results: CT of head ordered..."

Only one set of vital signs is documented on the Post Fall Assessment
dated 2/26/14 at 18:00: Pulse: 88, Respirations: 16, Blood Pressure: 107/54 and one neurological assessment: AO (alert and oriented) x 1.


"Policy and Procedure Directive
Subject: Falls Prevention and Resources

Date: 5/05 Revised: 6/13

I. Scope: This policy applies to (name of hospital), its employees, medical staff...regardless of service location or category of patient...

II. Purpose:

A. Establish guidelines for mitigating the risk of patient falls.
B. Establishing a framework for assessing risk factors for...falls, implementing intervention for reducing the risk for falling, and protecting patients from injury if a fall should occur.
C. Establish guidelines for the prevention of ...falls through the diligent assessment, ongoing communication and appropriate proactive action.
D. Establish guidelines to define action in the event of a fall and complete the required follow-up assessments and documentation.
E. Establish guidelines for staff to retain responsibility for patient safety at all times, even if family members are present.

III. Definitions:
...E. Factors which may increase risk for falls include:

...2. Age...

5. Use of restraints...

8. Difficulty understanding/retaining instructions...

14. Taking high risk medications...


F. Secondary diagnoses which may increase risk for falls include, but are not limited to the following:

...4. Bowel bladder incontinence/frequent toileting...

8. Dementia/Alzheimer's


IV. Policy:
...This hospital will take steps to reduce the number and severity of patient falls by doing the following:

A... Complete frequent vital signs on falls with injury... Every 15 minutes x 4, every 30 minutes x 2, every hour x 2, then every 4 hours x 48 hours...


V. Procedure:

A. Initial Falls Risk Assessment

1. Upon entry into the hospital system...a registered nurse (RN) should...complete the Morse Fall Scale Risk Screening Tool...

B. Fall Risk Assessments:

1. Morse Scale Assessment:...

c. ...score 45 and above are considered 'High Risk' for falls.

d. Patients that were admitted with any reason related to a fall...will be assigned an 'E.' The patient assigned an 'E' rating will be considered an EXTREME fall risk for the duration of that hospitalization...

h...Table A Medication Classifications provides some of the highest risk medication classes that place the patient at highest risk for falls." (List includes psychotropics (Haldol) and Blood Thinners (Lovenox and Aspirin).

C. Medication Classification Assessment:

4. As part of the initial assessment, a pharmacist will review medications
and supplements to assess for medications that increase risk for falls.... The nurse will be responsible for incorporating this information into the care plan...

E. Mandatory Fall Alert Interventions:

1. All patients identified as at risk for falls should have interventions implemented to alert other healthcare workers....of the fall potential.

2. Minimally, all of the following measures will be implemented at all times:

a. For high/extreme risk, a yellow armband must be place on the wrist and yellow or no-slip/skid socks be applied...

f. Make sure the bed is secured and locked in low position...and 2-3 side rails up...

I. Post-Fall Management:

1. Assess for injury...

4. Obtain vital signs, a physical assessment and neuro (neurological) checks after every fall:

a. Every fifteen minutes x 4, every 30 minutes x 2, every 1 hour x 2, every 2 hours x 2, then every 4 hours x 48 hours...

10. Modify the Interdisciplinary Plan of Care as patient's condition warrants...

14. If any injury has occurred, regardless of location, an intense analysis of the fall is mandatory. This will include primary staff caring for the patient, Clinical Coordinators, Nursing Directors, Risk Manager, Falls Champions and other pertinent staff...

Q. Enforcement:

All hospital staff and Medical Staff Members whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy. Failure to comply with this policy will be subject to appropriate performance management pursuant to all applicable policies and procedures, including the Medical Staff Bylaws, Rules and Regulations."


Patient Identifier (PI) # 1's Interdisciplinary Plan of Care dated 2/15/14 through 2/20/14 revealed:...

"Problem # 2: Safety

Goal: Patient will be free from fall and will remain injury free throughout stay.

Key Interventions:

1. Keep bed at lowest position, keep call light and phone within reach... bedrails x 2 up at all times...

2. Fall Risk Education...

3. Offer frequent toileting and frequent rounds.

Resolved/Ongoing/Date: no documentation."


Although PI # 1 was identified on admission as a high risk for falls, the hospital failed to ensure nursing staff maintained and modified a Plan of Care for falls to ensure:

- PI # 1's bed alarm was on at the time of the fall;

- two to three side rails were in the up position, not four as documented;

- Nursing staff attempted and documented the use of other strategies to reduce falls such as use of hip protectors and bedside mats and

- the patient's vital signs and neurological assessment were done every fifteen minutes x 4, every 30 minutes x 2, every 1 hour x 2, every 2 hours x 2, then every 4 hours x 48 hours post fall.