HospitalInspections.org

Based on medical record (MR) review, document review and interview, in 1 of 1 hospital investigations reviewed, the hospital did not adequately identify areas for process improvement and did not develop, implement, or evaluate a plan for improvement. Also, administrative staff identified falls as an area of concern, however, the facilty failed to implement performance improvement (PI) actions and measure outcomes. This puts patients at risk for potential harm.

Findings include:

-- Per MR review, Patient #1's ambulation status was one assist with contact guard (CG). One of the fall interventions documented was assisted toileting using "Arms Reach" rule. On 4/17/2021 at 3:05 am, a staff member assisted Patient #1 to the bathroom. While waiting outside the room, the staff member heard Patient #1 fall. Patient #1 was found bleeding on the bathroom floor. He was not breathing. A Code Blue was called and care ensued.

-- Per review of the hospital's root cause analysis (RCA) of Patient #1's care, conducted on 5/5/2021, the standard of care was met. However, per review of Patient #1 MR it was identified that one of the fall interventions documented was assisted toileting using "Arms Reach" rule. Patient #1 was left alone on the toilet.

-- Per interview of Staff A, Chief Nursing Officer and Staff B, Clinical Nurse Specialist on 4/12/2022 at 11:50 am, the current Fall scale was developed after determining that some patients are more at risk to falls with harm than others, so the focus was on adding extra interventions for those patients. In the MR, the standard fall prevention interventions and the standard fall prevention interventions for patients at risk to fall with potential for harm, automatically populate when the standard is checked. However, per the Fall policy and procedure (P&P) some of the interventions that automatically populated should have been chosen by the RN after patient assessment. This appears to be a problem in the MR system. From a clinical standpoint if a patient is getting up from a bed/chair without assistance, the "Arms Rule" shouldn't apply as an intervention. The hospital is currently reviewing the Fall Protocol P&P.

-- Per interview of Staff A, Chief Nursing Officer on 3/30/2022 at 2:10 pm, the hospital has identified falls as an area of concern and are looking at PI initiatives. An occurrence report is done for any descent to the floor. They are looking at the definition of a fall, is it for any descent to the floor even if assisted or just for unplanned falls. They are looking at falls with injuries, bathroom falls, and call bell related falls. The plan is to roll out "purposeful rounding" in May 2022. Purposeful rounding helps with many areas, for example whiteboard communication, accountability, monitoring and auditing.

-- Per review of "AAPI Falls Subcommittee Meeting" minutes dated 3/14/2022, the facility is looking at implementing a no pass zone and purposeful rounding on all patients hourly. A meeting of managers from each clinical area, along with the directors and members of the fall team is planned. Monthly fall tracking visuals are going to be displayed on all units. The group asked for the falls total from 2021 and the current year 2022 to be displayed for better staff understanding.

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Based on document review, medical record (MR) review and interview, (1) in 3 of 7 (Patient's #1, #3 and #4) MRs reviewed, patients identified as "risk to fall with harm" did not have accurate and/or consistent documentation in the MR on all the preventative measures implemented. (2) In 1 of 7 MRs reviewed, Patient #2 was identified as a fall risk. Staff did not ensure all fall preventive measures were maintained. (3) Administrative staff identified falls as an area of concern. However, no additional performance improvements projects had been implemented at the time of this survey and the facility does not provide yearly fall education to staff. This could increase a patients risk to fall and lead to untoward outcomes.

Findings related to (1) include:

-- Review of the facility's policy and procedure (P&P) titled "Fall Protocol," last reviewed 11/2020, indicated patients will be assessed on admission and daily, and as needed to determine their "risk for falls" and "risk to fall with harm". At the conclusion of the assessment the inpatient/resident should be categorized into one of three categories:
a. Universal Safety
b. Fall Risk
c. Fall with Harm Risk

The Fall/Harm Risk Assessment requires staff to answer all 3 questions:
#1a - Does patient need assistance with standing, walking or toileting? No/Yes
#1b - Does patient attempt to get out of bed (OOB)/chair unassisted when assistance is needed? No/Yes
#2 - Has the patient fallen during the last 6 months or during this admission: No/Yes/This admission/last six months/Unable to determine
#3 - Are there harm risk factors based on your nursing judgement? No/Yes/ See guide below

Harm Risk Assessment Guide:
Age: Is the patient 85 years old or older?
Bones: Does the patient have a bone condition, including osteoporosis, a previous fracture, prolonged steroid use or metastatic bone cancer?
Coagulation: Does the patient have a bleeding disorder, either through the use of anticoagulants or underlying clinical conditions?
Surgery: Is this a recent post-op patient, especially a patient who has had a recent lower limb amputation, major abdominal or thoracic surgery?
Other:
Conclusion:
ALL patients Universal Safety Interventions
YES to Question #1a, OR #1b, OR #2 Fall Risk
YES to Question #1a, OR #1b OR #2 and Question #3 Fall with Harm Risk

All patients - Universal Safety Interventions:
1. Orient to call system
2. Instruct to call for assistance before getting out of bed or chair
3. Non-slip footwear when patient is OOB
4. Call bell, personal items and phone within reach
5. Physically safe environment - no spills, clutter or unnecessary equipment
6. Bed in lowest position, wheels locked, appropriate side rails in place
7. Room/bathroom lighting operational, light cord in reach.(1-7).

Fall Risk Interventions - Patient screens YES to Question #1a OR #1b, OR YES to Question #2:
1. Universal Safety Interventions (1-7 above)
2. Provide visual clue: yellow wrist band
3. Monitor for mental status changes and reorient to person, place and time as needed
4. Monitor gait and stability
5. Review medications for side effects contributing to fall risk
6. Reinforce activity limits and safety measure with patient and family). (1-6)

Selected Fall Risk Interventions:
Check all interventions implemented as deemed appropriate based on a patient's needs
- Use of Alarm(s) options: bed alarm, voice tab alarm, chair alarm
- Discuss with provider need for PT (physical therapy) consult
- Assisted toileting using "arms reach" rule (arm's length away: to keep eyes on the pt. at all times and close enough to intervene quickly if needed; including toileting and bathing) for commode or bathroom
- Hourly rounding
- Move patient closer to nurses' station
- Enhanced supervision

Fall with Harm Risk - Patient screens Yes to Question #1a OR #1b or #2 Interventions AND YES to Question #3:
1. Universal Safety Interventions (1-7)
2. Fall Risk Interventions (1-6)
3. Any selected Fall Risk Interventions
4. Provide visual cues: Yellow wrist band and red socks

-- Review of Patient #1's MR revealed, nursing assessments dated 4/15/2021 at 12:27 pm, 4/15/2021 at 7:20 pm, 4/16/2021 at 8:15 am, each documented that Patient #1 was a fall with harm risk. He was alert and oriented and had made no attempts to get OOB or chair without assistance, no barriers to learning. All universal safety interventions were implemented and standard fall precautions were in place which included: assisted toileting using "arms reach" rule for commode or bathroom and hourly rounding.

On 4/16/2021 at 9:40 pm, the nursing shift assessment indicated, Patient #1 was alert and neurologically intact. Nonproductive cough present, with shortness of breath (SOB) on exertion. He turns and positions himself. Mobility with the assist of one with contact guard (CG). No attempts have been made to get OOB or chair without assistance.

Normal Safety Precautions (Per P&P called Universal Safety Interventions) were documented, for example, non-slip footwear, call bell, personal belongings and phone within reach, physical environment safe, bed in low position.

Risk to fall standards documented included: provide visual cue: yellow wrist band, monitor for mental status changes and reorient to person, place and time prn, monitor gait and stability.

Risk to fall with harm standards documented included: monitor gait and stability, assisted toileting using "Arms Reach" rule, hourly rounding. visual cues: yellow wrist band, red socks.

Risk to fall with harm interventions documented included : bed alarm, physical therapy consult, education to patient and family about fall risk.

On 4/17/2021 at 3:05 am, Staff C, Registered Nurse (RN) documented, Patient #1 called for assistance to go to the bathroom. A staff nurse ambulated him to the bathroom with CG and walker. The nurse heard his fall from outside the room and found him on bathroom floor bleeding. The nurse pressed the code button.

On 4/17/2021 at 7:53 am, a provider documented that a Code Blue was called when patient was found unresponsive in the toilet room with significant hematoma on his right eye and blood on the floor. Per report, patient was taken to the toilet and subsequently had an unwitnessed fall, hit his head. Unclear if patient sycopized before falling or fell and lost consciousness and went into cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated and went on for 8-10 minutes. Patient initially achieved return of spontaneous circulation (ROSC) after 2 rounds of CPR and was transferred to the bed, subsequently lost his pulse. Had another 2 rounds of CPR, received 2 epinephrine, total of 1 ampule of bicarb and achieved ROSC again. Numerous tests were done. He was transferred to the Intensive Care Unit (ICU). Injuries included a right orbital floor fracture with periorbital and supraorbital soft tissue scalp hematoma and swelling, Cervical 6 fracture, and several acute appearing bilateral rib fractures.

-- Per interview of Staff C, RN on 4/4/2022 at 8:50 am, he/she cared for Patient #1 on the night that the fall occurred. Patient #1 was alert and oriented. The shift report indicated he could ambulate with 1 assist and his rolling walker. Staff C recalled assisting him to the bathroom at around 1:30 am. He had put his call bell on for assistance both to go to the bathroom and when he was finished in the bathroom to return to bed. Later around 3:00 am, the patient again used his call bell to be assisted to the bathroom. Another nurse (Staff G, RN) was working and asked Staff C if the patient could ambulate to the bathroom. He/she told Staff G the patient needed 1 assist and his walker. The patient fell while in the bathroom. Staff C felt the patient was alert enough to call for assistance when needed, as he had done earlier.

-- Per interview of Staff G, Traveler RN on 4/4/2022 at 10:30 am, he/she walked Patient #1 to the bathroom, prior to the fall. Prior to taking the patient to the bathroom, Staff G spoke with his assigned nurse and was told the patient could ambulate to the bathroom with his walker and 1 assist. Patient #1 was alert and oriented. He ambulated well with his walker. Staff G stood outside the room to wait for the patient to be done. Staff G heard a noise and went to the bathroom and found Patient #1 on the floor. Staff G called the code team and started CPR.

-- During Interview with Staff B, Clinical Nurse Specialist on 4/12/2022 at 11:50 am, he/she indicated, although the documentation of "arms length" was in the MR, it should not have been automatically populated and that was a fault with the MR. Patient #1 was alert and oriented and would not have required "arms length" supervision.

-- Review of Patient #3's MR revealed on 3/28/2022 at 8:55 pm, nursing documented he was risk to fall with harm. All the standard precautions were implemented along with the standards for risk to fall with harm. Additional interventions selected by nursing staff included, bed alarm, PT consult and education given to family/patient regarding fall risk. On 3/29/2022 at 12:40 am, nursing documented Patient #3 was a risk to fall with harm. All the standard precautions were implemented along with the standards for risk to fall with harm. There were no additional interventions documented (e.g., bed alarm and education given to family/patient regarding fall risk) that were documented in prior assessment).

-- Review of Patient #4's MR revealed on 3/28/2022 at 4:00 pm, nursing documented she was a risk to fall with harm. All the standard precautions were implemented along with the standards for risk to fall with harm. Additional interventions selected by nursing staff included move closer to nursing station. (There was no documentation of education given to family/patient regarding fall risk.) On 3/28/2022 at 7:00 pm, nursing documented, Patient #4 was a risk to fall with harm. All the standard precautions were implemented along with the standards for risk to fall with harm. There were no additional interventions selected by nursing staff. On 3/29/2022 at 8:00 am, the nursing assessment lacked a fall risk assessment.

-- During interview with Staff D, Nurse Manager on 3/30/2022 at 10:30 am, he/she confirmed the above findings and indicated the bed alarm should be selected by nursing staff if in place. Education about fall risk should also be documented with each assessment for patients at risk to fall with harm. The fall assessment portion of the MR should be completed on every shift by the nurse.

-- Per interview of Staff A, Chief Nursing Officer and Staff B, Clinical Nurse Specialist on 4/12/2022 at 11:50 am, normal safety precautions are included under the "Fall" section in the MR as part of the RN assessment. The current Fall scale was developed after determining that some patients are more at risk to falls with harm than others, so the focus was on adding extra interventions. In the MR some of the interventions automatically populate, this appears to be a fault in the MR system. The "arms reach" intervention should be selected by the nursing staff and not be automatically populated. From a clinical standpoint if a patient is getting up from a bed/chair without assistance, the "Arms Rule" shouldn't apply as an intervention. The hospital is currently reviewing the Fall Protocol P&P.

Findings related to (2) include:

-- Review of the facility's P&P titled "Fall Protocol," last reviewed 11/2020, indicated the registered nurse (RN) will implement appropriate interventions to prevent falls.

-- Review of Patient # 2's MR revealed on 10/24/2021 at 8:00 am, 12:00 pm and 4:00 pm, nursing documented she was a risk to fall. Fall interventions included "Risk to Fall Standards", "Risk to Fall Additional interventions" and "Normal Safety Precautions". At 6:30 pm, the patient had an unwitnessed fall from her hospital bed to the floor.

-- During interview of Staff E, RN on 4/4/2022 at 11:00 am, prior to the unwitnessed fall, Staff E had helped reposition the patient, the bed alarm sounded, so he/she turned it off, finished repositioning the patient and forgot to turn the bed alarm back on. When Staff E left the room the patient had 3 siderails up (2 on the sides at the head of the bed and 1 on the side at the foot of the bed), her call bell was next to her and the television was on.

-- During interview of Staff F, Director of Quality on 4/11/2022 at 10:00 am, he/she acknowledged the above finding.

Findings related to (3) include:

-- Review of the facility's P&P titled "Fall Protocol," last reviewed 11/2020, indicated fall prevention/injury reduction activities are incorporated into Nursing Orientation. Ongoing education will be completed as needed to meet the learners needs or changes in practice.

-- During interview of Staff A, Chief Nursing Officer on 3/30/2022 at 2:10 pm. The hospital has identified falls as an area of concern and are looking at possible performance improvement (PI) initiatives. They are currently reviewing the Fall Protocol P&P in their Falls Committee. The Falls Committee has met once on 3/14/2022.
Some Performance Improvement plans have been identified, however, none had been implemented as of the exit date of this survey.

-- During interview of Staff A, Chief Nursing Officer and Staff B, Clinical Nurse Specialist on 4/12/2022 at 11:50 am, he/she indicated the hospital does not provide annual education /competencies for fall prevention.