HospitalInspections.org

Based on observation, interview and record review nursing services failed to ensure and enforce policies and procedures related to high fall risk was implemented to control risk of injury to three (3) of six (6) patients. (ID# 2, 5, 7).

Findings include:

Observation on May 23, 2017 at 1000 revealed three (3) of the six (6) high fall risk patients revealed the following as indicated in their care plan:

Patient #2: A 56-year-old, admitted on 5/22/2017, post-operative right knee replacement patient did not have a yellow risk armband on.
Patient #5: A 76-year-old patient, admitted on 5/23/2017 with septic arthritis, did not have yellow non-skid footwear or a yellow risk armband.
Patient #7: A 85-year-old patient admitted 5/22/2017 with right heel ulcer did not have yellow non-skid footwear or a yellow risk armband on.

Record review of the facility policy titled "Fall Management-Patient Care", dated September 2014, stated:
B. Universal Fall Precautions:
9. Document in patient's electronic medical record. Update patient care plan every shift.
C. High Risk Interventions
More interventions by the healthcare team are necessary for those patient ....
1. Place yellow fall risk armband on the patient, identifying the patient as a high risk.
2. Provide the patient with yellow non-skid footwear, used to identifying the patient as a high risk.

Interview on May 23, 2017 at 1015 with the nurse manager, RN (#H), she stated "they should have a yellow armband and yellow socks on. We put red socks on them if they have already fallen. Falls are a high priority in the hospital".