HospitalInspections.org

Based on interview and record review, the facility failed to accurately assess fall risk and clearly state ambulation assistance plans in nursing care plans for 1 of 2 current patients (#7) and 1 discharged patient (#1) resulting in increased risk of falls for all patients. Findings include:

Policy Review:
Patient Care Planning, #40.4.495, dated 01/14, was reviewed on 11/25/14 from 1400-1600. The policy states: "It is the responsibility of the patient's RN (Registered Nurse) to use the nursing process to assess the patient, analyze the data, and then create, implement and evaluate a plan of care."

Fall Prevention, #40.4.266, dated 11/12, was reviewed on 11/25/14 from 1400-1600. The policy states:
--"History of falling: This is scored 25 if the patient has fallen during the present hospital admission, within one week prior to admission or if there was an immediate history of physiological falls, such as from seizures or an impaired gait prior to admission."
--"A Morse Fall scale score of 45 or greater for inpatient units will identify patients as high risk and these patients need to be targeted for fall prevention strategies."

Record Review & Interview for patient #7:
1. On 11/25/14 at 1140 patient #7's clinical record was reviewed with nurse E. Patient #7 was admitted 10/22/14 with diagnoses of redness and swelling in her right foot, insulin-dependent diabetes mellitus and history of peripheral vascular disease. Nurse E stated that patient #7 is allowed to ambulate with "2 max (maximum) assist." Nurse E was asked if the level of assistance was ordered by a physician or nursing judgement. Nurse E responded that patient's ambulation status reverts to the last physician's order if no new order for ambulation is written. Nurse E stated that patient #7's last ambulation order was written on 11/22/14 and reads "bed rest for 6 hours."
2. On 11/25/14 at 1145 patient #7 was asked if she gets out of bed. The patient stated that she is not allowed out of bed per physician's orders and hasn't been getting out of bed for several days.
3. On 11/25/14 at 1150 nurse E stated that the Daily Focus Assessment Report is part of the patient's daily nursing care plan. On 11/25/14 patient #7's Daily Focus Assessment Report stated that patient #7 was allowed to "ambulate with assistance." Under "Mobility" the patient's 11/25/14 Daily Focus Assessment Report states: "Bed rest With assistance."
4. On 11/25/14 at approximately 1155 patient #7's Patient Care Plan Report for 11/25/14 was reviewed. The Plan states: "provide 1-2 person assist for transfers and ambulation, as per therapy recommendations." The report also states: "assist patient in using assistive devices PRN (as needed)."
5. On 11/25/14 at approximately 1200 review of the patient TeleTracking list revealed that patient #7 "failed out PT (Physical Therapy) Therapy."
6. On 11/25/14 at approximately 1200 Staff E confirmed that patient #7's care plan does not state the patient's ambulatory status or assistive device needs.

Record Review & Interview for patient #1:
1. On 11/25/14 from approximately 1400-1530 review of patient #1's clinical record revealed that the patient was admitted 12/5/13. Patient #1's History and Physical, dated 12/5/13, states that the patient "presents to the ED (Emergency Department) with dyspnea and generalized weakness this morning." The initial Morse Falls Scale completed upon admission notes a "History of Falls" and adds 25 points to the patient's Fall Risk Score for this history. Patient #1's Fall Risk Score was 80 on 12/5/13 at 1747.
2. On 11/25/14 from approximately 1400-1530 review of patient #1's clinical record revealed that the patient's History of Falls score (25 points) was left off the patient's Morse Falls Scale reviews on: 12/5/13 at 2155, 12/6/13 at 2100, 12/7/13 at 2123 and 12/8/13 at 0800, lowering the patient's Fall Risk Score on all four days. Staff C stated that patients' Morse Fall Risk scores guide staff in picking care plan interventions to reduce fall risk.
3. On 11/25/14 at approximately 1500 staff C stated that patient #1 had been instructed to call for assistance with ambulation. Staff C confirmed that patient #1's care plan did not state that the patient was instructed to call for assistance with ambulation.
4. On 11/25/14 from approximately 1400-1530 review of patient #1's clinical record revealed that on 12/8/13 patient #1 sustained a fall with injury.
5. During record review on 11/25/14 from 1400-1530 staff C confirmed the above findings.