HospitalInspections.org

Based on interview, incident and medical record documentation reviewed for 1 of 1 patient that fell and experienced a hip fracture (Patient 1), and review of hospital policies and procedures, it was determined that the hospital failed to fully develop and implement P&Ps that ensured the patient's right to receive care in a safe setting:
* The hospital failed to develop and enforce P&Ps to ensure patients received care in a safe setting and were appropriately supervised and prevented from falls and injuries.

Findings include:

1. a. The P&P titled "Fall Risk Assessment, Prevention, and Management" dated "Final Approval 01/2021" was reviewed. It reflected:
* "The principle objectives of this policy are 1) to standardize the assessment of patient risk for fall, using an evidence-based tool; 2) to implement interventions based on the patient's identified risk; and 3) to specify interventions to be taken if a fall occurs."
* "Assess acute care inpatients for presence of fall risk factors and calculate the level of fall risk on admission to the unit, twice daily, and PRN, if the patient's condition changes using the Johns Hopkins Fall Risk Assessment tool located in the electronic medical record."
* "All patients at low fall risk and above ... implement basic safety interventions listed on Table A ... Patients at moderate fall risk ... implement the moderate fall risk interventions ... in addition to interventions for low risk ... Patients at high fall risk ... implement high fall risk interventions in addition to interventions for low and moderate risk."
"Table A
Low Fall Risk: 0-5 points
-Fall risk assessed every shift and with condition change.
-Fall risk comunicated at handoff.
-Patient and family educated on fall risk using teachback method initially and with reminders as needed.
-Side rails up x2
-Non-skid slippers or other supportive footwear when OOB
-Environment examined for safety:
-Clear pathway of obstructions
-Tripping/slipping hazards
-Lighting
-Wheels locked on bed/chairs
-Call light/personal items within reach
-Use of call light demo'd on admit w/reminders as needed.
-Purposeful rounding per unit protocol
-Bed in lowest/locked position
Moderate Risk: 6-13 points
-Implement measures under low risk, reinforce 'call so you don't fall.'
-Fall-risk added to care plan
-Yellow armband on patient
-Door sign placed; consider use of High Fall Risk sign as indicated.
-If patient confused/impulsive, or physically unable to maintain position, set bed alarm on minimum 'sit' when in bed.
-If patient confused/impulsive, or physically unable to maintain position, use TAB alarm or chair pad sensor alarm when in chair.
-Remain at 'arm's length' when patient up and explain to patient; document refusals.
-Gait belt in use as indicated.
High Risk: 14 points or higher
-Implement measures under low and moderate risk, reinforce 'call so you don't fall.'
-Curtains/door open for visibility
-Move pt closer to nurses' station as able.
-Consult PT as indicated.
-If family supervising patient ...
-Consider self-releasing alarmed or non-alarmed belt when patient up in chair.
-1:1 companion as indicated
-Low bed and/or floor mats in use as indicated
-Consider use of High Fall Risk sign"
* The P&P was not fully developed. For example, it lacked time frames for completion of fall related tasks, and identification of staff responsible for fall assessments, care planning, and interventions including those listed in Table A above.

1. b. The P&P titled "Patient Rights and Responsibilities" dated "Final Approval Date 12/2018" was reviewed. It reflected:
* "Staff will observe the following Patient Rights for each patient entrusted to their care. Professional care: ... To provide a safe and private environment, free of abuse or neglect."

2. The medical record of the Patient 1 reflected the patient presented to the ED on 05/06/2020 at 0036 for AMS.
* While in the ED, the patient experienced new seizure activity.
* On 05/06/2020 at 1215, the patient was admitted to the NTCU.
* On 05/06/2020 at 1607, RN Progress Notes reflected "Patient was found down and not witnessed to fall ... time of fall: 1330 ... alert, a/o x1, calling out for [family member] ... Patient's description of fall: UTA ... Suspected injury: Yes. R hip injury ... Patient was assisted back to bed with pt placed on backboard. RRT staff, lift team staff, pt's nurse and three other unit staff assisted back to bed."

* On 05/06/2020 at 1702, an Orthopedic Consult Note reflected "78 y.o. [male/female] presented to Salem Hospital with altered mental status. [He/she] has a VP shunt due to NPH that has been complicated by multiple falls ... In the ER ... brief self termination tonic-clonic seuzure type activity ... At some point during the day today [he/she] was able to get out of bed and had an unwitnessed fall landing directly onto [his/her] right hip. [He/she] was found on the ground. Orthopedics was consulted regarding further management. [He/she] did suffer a ground-level fall in October and had a left hip hemiarthroplasty ... Impression: Right femoral neck fracture with displacement and angulation ... Recommendation is for a right hip hemiarthroplasty."

* On 05/07/2020 at 1551, an Operative/Invasive Procedure Note reflected "Postoperative Diagnosis: right displaced femoral neck fracture. The patient will work with physical therapy in the hospital. The patient has posterior hip precautions and is weightbearing as tolerated ..."

* On 05/14/2020 at 1129, Discharge Summary reflected "... patient had a fall during the hospital stay, and developed a right hip fracture ... patient underwent right hip hemiarthroplasty with wound vac placement."

* There was no documentation in the medical record that reflected the RN assessed the patient's risk for falls and developed and implemented a nursing care plan based on an assessment, upon arrival to the NTCU, or at any time before he/she fell.

3. The hospital's internal investigation document titled "Improvement Project Title: Fall with Harm 5/6/20" was reviewed and reflected the following:
* " [Patient] had seizures."
* " ...seizure precautions were indicated."
* "Patient ... fell and sustained a broken femur/hip on 5/6/2020."
* "...pads [on side rails] were in place, causing potential confusion and a greater height from which the patient fell."
* "Patient fell from a substantial height."
* "Surgery needed that was not a part of initial admission."

4. During interview with CIO, DPS and RPSM on 05/10/2021 at 1030, the following information was provided regarding the incident involving Patient 1:
* The patient had AMS.
* The patient was transferred from the ED to the NTCU.
* Approximately 1 hour after arrival to the NTCU, the patient was alone in his/her room, and experienced an unwitnessed fall and hip fracture that required surgical intervention.
* There was no documentation that reflected the RN assessed the patient's fall risk upon arrival to the NTCU or at any time prior to when he/she fell.
* There was no documentation that reflected the RN developed a nursing care plan that addressed the patient's fall risk before the patient fell.

Based on interview, review of medical record and incident documentation for 1 of 1 patient for provision of nursing services (Patient 1), and review of P&Ps, it was determined that the hospital failed to ensure the RN supervised and evaluated patient's condition in accordance with hospital P&Ps as follows:
* The hospital failed to ensure the RN evaluated the patient's fall risk; and failed to intervene and prevent the patient, who had a history of falls, AMS, and recent seizures, from falling.

Findings include:

1. Refer to the findings cited at Tag A144, CFR 482.13(c)(2) - Standard: Patient Rights: Care in Safe Setting. Those findings reflect the hospital failed to ensure the RN supervised and evaluated the nursing care of patients in accordance with hospital P&Ps.

Based on interview, review of medical record and incident documentation for 1 or 1 patient for provision of nursing services (Patient 1), and review of P&Ps, it was determined that the hospital failed to ensure the RN developed a nursing care plan in accordance with hospital P&Ps as follows:
* The hospital failed to ensure the RN developed and implemented a nursing care plan, including goals, and interventions based on an evaluation of the patient's fall risk and individualized needs.

Findings include:

1. Refer to the findings cited at Tag A144, CFR 482.13(c)(2) - Standard: Patient Rights: Care in Safe Setting. Those findings reflect the hospital failed to ensure the RN developed a nursing care plan that included goals, nursing care, and interventions based on an assessment of the patient's fall risk and individualized needs in accordance with hospital P&Ps.