HospitalInspections.org

Based on record review and staff interviews, the facility failed to ensure that medical records were accurately written and that documentation was completed promptly following patient falls which occurred between 06/01/13 through 07/01/13 for 5 of 11 sampled patients (#9, 12, 13, 17 and 18). The documentation should include assessments, notification to the physician, treatments, and the patient's response to those treatments. This deficient practice could result in difficulty if not inability of the staff to recall, for future purposes, a patient's condition immediately following a fall. The findings are:

A. Review of Patient #9's medical record revealed the following:
1. Patient fell on 06/26/13 at 12:42 am. The patient's fall was unwitnessed.
2. The provider was notified on 06/26/13 at 2:32 am of the fall. The provider notification indicated the following: "Patient was found in the bathroom on his knees, after a fall on his knees. Patient stated he did not hit his head or any other part of his body except fell to his knees in the bathroom. "
3. There is no documentation of a fall assessment, including neurological status and vital signs, by the nurse subsequent to the incident. According to the record, an assessment was performed by the nurse at 4:19 am, four hours after the fall, but no details of the assessment are in evidence. The patient was later diagnosed with Guillain-Barre syndrome (a rare neurological illness, with a loss of motor function beginning in the extremities and possibly rising quickly to the respiratory muscles).
4. In interview on 07/10/13 at 5:30 pm, RN #9 (a clinical supervisor on 2100 unit) confirmed the lack of documentation of a fall assessment, including neurological status and vital signs, although the hospital's "Falls Protocol" dictated that such documentation follow an unwitnessed fall.

B. Review of Patient #12's medical record of two hospital stays during the month of June revealed the following:
1. Patient #12 was hospitalized from 06/13/13 - 06/20/13; he fell on 06/15/13 at 4:45 pm.
2. The provider was notified on 06/15/13 at 4:45 pm of the fall. The provider notification indicated the following: "Patient was on knees in front of toilet, fell over toward his left side."
3. There is no documentation to indicate that a fall assessment, including neurological status and vital signs, was conducted by the nurse subsequent to the incident.
4. In interview on 07/11/13 at 9:45 am, RN #11 (a clinical supervisor on 2100 unit) confirmed the lack of documentation of a fall assessment, including neurological status and vital signs, although the hospital's "Falls Protocol" dictated that such documentation follow an unwitnessed fall.
5. Patient #12 was hospitalized from 06/25/13 - 06/28/13; he fell on 06/27/13 (time unknown), according to the "Incident Fall" Report, dated 06/01/13 through 07/01/13. The "Incident Fall" Report (which is not part of the patient's chart) revealed the following: "Patient found down on the floor in the bathroom. Patient was able to reach call light in the bathroom to call for assist. VS [vital signs] were taken and were stable, blood glucose taken and found to be 324. Patient stated he hit his head and shoulder. Patient neurologically intact. MD [name of MD] notified. MD saw patient felt he was fine. Acetaminophen 650 mg ordered for patient's complaints of head ache. Will continue to monitor patient for any adverse signs and symptoms of injury."
6. No documentation is in the medical record to indicate that a fall occurred. Furthermore, there is no documentation that a fall assessment, including neurological status and vital signs, was conducted by the nurse subsequent to the incident, although the hospital's "Falls Protocol" dictated that such documentation follow an unwitnessed fall by a patient with a possible head injury .
7. In interview on 07/11/13 at 10:30 am, RN #11 confirmed the lack of documentation of a fall assessment, including neurological status and vital signs. RN #11 stated that the reason for the lack of documentation of these falls was that "the patient comes into the hospital frequently and the staff are very familiar with him."

C. Review of Patient #13's medical record revealed the following:
1. Patient fell on 06/23/13 at an unknown time. The patient's fall was not witnessed while the patient was on the hospital's Clinical Institute Withdrawal Assessment (CIWA) protocol.
2. There is no documentation of a comprehensive fall assessment by the nurse subsequent to the incident. There was a retroactive charting or a late entry nursing note in the medical record dated 06/24/13, a day after the event. The late entry nursing note indicated the following:
a) a post-fall assessment was done and the patient's physician was notified;
b) a dedicated sitter was obtained for the patient at 11:00 am on 06/23/13 by the nursing supervisor;
c) the CIWA protocol was in use and that the patient had been scoring a 27, indicated as very high risk during assessment that morning;
d) patient had been transferred to that particular room the previous evening, to be more visible from the nursing station, but at the time of the fall, there was nobody at the nursing station, due to staff being busy with other patients.
3. In interview on 07/11/13 at 10:45 am, RN #11 confirmed the lack of documentation of a fall assessment, including neurological status and vital signs (irrespective of the indication in the nursing note that an assessment was performed), although the hospital's "Falls Protocol" dictated that such documentation follow an unwitnessed fall by a patient with a possible head injury .

D. Review of Patient #17's medical record revealed the following:
1. Patient fell on 06/22/13.
2. According to the "Incident Fall" report (which is not part of the patient's chart), dated 06/01/13 through 07/01/13, revealed the following: "At 2315 [11:15 pm] went to check on patient. Patient was found on floor conscious, alert and in no immediate distress. Clinical Supervisor was notified. Vital signs recorded, and patient assisted back into bed. Patient education was provided on the importance of not climbing over bed rails and call light usage for help. Patient agreed that he understood."
3. No documentation was found to indicate that a fall had occurred in the medical record. There was no documentation that a fall assessment, including neurological status and vital signs, was conducted by the nurse subsequent to the incident, although the hospital's "Falls Protocol" dictated that such documentation follow an unwitnessed fall by a patient with a possible head injury.
4. In interview on 07/11/13 at 2:45 pm, RN #10 (a clinical supervisor on the 3200 unit) confirmed the lack of documentation of a fall assessment, including neurological checks and vital signs.

E. Review of Patient #18's medical record revealed the following:
1. Documentation is incomplete regarding a fall that occurred on 06/14/13.
2. In interview on 07/11/13 at 2:55 pm, RN #10 confirmed that the provider was not notified of the patient's fall and that there was a lack of details describing the incident in the medical record.

F. Review of the facility's policy titled "Falls Protocol" revised on February 2012, revealed the following: "...Immediately following a patient fall, the Fall Response Team will be paged to the area to initiate a post fall review. Each patient that falls will have details of the fall, their post fall assessment, and all interventions documented in the medical record. The physician of the patient who falls will be notified of the patient's fall...Post-Fall Management: Immediately following a fall initiate the post fall response and documentation; Complete diagnostic studies and physician requests as ordered;
Take the following actions in the event of a witnessed fall, in which patient is known to have sustained no head trauma from the fall: Check for injuries. Check blood pressure and pulse sitting and standing (if patient is able to stand). If indicated, check capillary blood glucose or obtain a physician's order to check blood glucose. For a maximum of 48 hours following the fall and/or until discharge: Obtain vital signs every 8 hours. Observe for possible injuries not evident at the time, e.g. joint range of motion, weight bearing, etc. Observe for change in mental status.
In the event of an unwitnessed fall, or one in which the patient sustains head trauma, or in which there is uncertainty about any head trauma: Alert the physician to anticoagulant use in any patient who has fallen. Use the same protocol outlined above...In addition perform neurological checks every 15 minutes x 4, every 30 minutes x 2, every hour x 4, and then every 4 hours for 24 hours. Alert the attending physician to any changes..."


Based on record review and interview, the hospital failed to ensure that the medical records of 3 active inpatients (#19, 20 and 21) requiring turning/repositioning every two hours were complete. Lack of documentation providing verification of such turning/repositioning yields uncertainty that the necessary turning/repositioning was done. The findings are:

A. Review of the medical record of Patient #19 revealed the following:
1. There is no documented evidence of activities of daily living, including turning/repositioning every two hours, between 07/11/13 at 6:45 am and the same day at 2:45 pm.
2. In interview on 07/11/13 at 2:45 pm, RN #24 (the manager for 3100 unit) stated that turning/repositioning every two hours around the clock was ordered for the patient. RN #24 verified that the medical record of the patient contains no written documentation that the prescribed activities of daily living, including turning/repositioning every two hours, had occurred for this patient.

B. Review of the medical record of Patient #20 revealed the following:
1. There is no documented evidence of turning/repositioning every two hours between 07/10/13 at 2:45 pm and 07/11/13 at 8:00 am.
2. In interview on 07/11/13 at 2:30 pm, RN #12 (a clinical supervisor) stated that turning/repositioning every two hours around the clock was ordered for the patient. RN #12 confirmed that the medical record of the patient contains no written evidence that the prescribed turning/repositioning had been performed between 07/10/13 at 2:45 pm and 07/11/13 at 8:00 am. RN #12 stated that the staff had received a general training on the software system approximately a year before.

C. Review of the medical record of Patient #21 revealed the following:
1. There is no documented evidence of turning/repositioning every two hours between 07/11/13 at 12:30 am and the same day at 2:30 pm.
2. In interview at 2:50 pm, RN #14 (who identified herself as a supervising nurse) stated that turning/repositioning every two hours around the clock was ordered for the patient. RN #14 verified that the medical record of the patient contains no written evidence that the prescribed turning/repositioning every two hours had been performed.


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