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LOVELACE REGIONAL HOSPITAL - ROSWELL
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on record review and interviews, the hospital failed to ensure patients received care in a safe setting by not following the patient's plan of care. This deficient practice has the potential for a patient to fall and sustain injuries.
The findings are:
A. Record review of Nurse Progress Notes dated 04/20/16 at 1900 [7:00 PM] revealed, "Pt [patient] found on floor clutching walker, by several staff members and nurse supervisor. Abrasions x 3 on UES [Upper extremities] treated and bandaged with Kerlex. Examined by ICU RN [Intensive Care Registered Nurse] and House Supervisor other injuries. None apparent at this time. MD notified. Attempted to notify wife. Left brief message on her answering machine."
B. Record review of Medsurg shift assessment, care plan, intervention dated 04/20/16 at 0700 (7:00 am) revealed a fall level score of 12 placing the patient at a high risk of falling.
C. Record review of Nurse Progress Notes dated 04/22/16 revealed, no sitter available per staffing.
D. Record review of Nurse Progress Notes dated 04/23/16 at 0440 (4:40 am) revealed, "Thump heard, patient found on floor laying on right side. Assisted patient to feet. C/O [complained of] head hurting and has bruise on right hip. Patient able to ambulate with walker and assistance of staff to bed. Ice pack to front of head, steri-strips to elbow [skin tear] yellow gown on, falling star on door frame, assisted to bed. Assisted patient to bed Tylenol 650 mg PO [by mouth] administered for head ache. PCT [patient care technician] sitting with patient. Bed alarm set, yellow gown on, monitoring."
E. On 08/22/16 at 9:30 am, during an interview, Staff #4 stated that the hospital identified issues regarding falls and a Fall Focus Study had been put into place in April 2016.
F. On 08/22/16 at 9:35 am, during an interview, Staff #5 stated the hospital was aware of Patient #1's unwitnessed falls during the patient's stay at the hospital and confirmed Patient #1 did not have a sitter present on either fall. Staff #5 also confirmed that Patient #1's bed alarm was off during both falls.