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OSF HEART OF MARY MEDICAL CENTER
NURSING CARE PLAN
Tag No.: A0396
Based on observation, document review, and interview, it was determined for 8 of 10 (Pt # 2, Pt # 5, Pt #6, Pt #7, Pt #8, Pt 9 and Pt #10) patients observed with fall reassertions, the Hospital failed to ensure the falls care plan precautions/interventions were implemented per policy. This has the potential to affect all inpatients and outpatients who require fall precautions by the Hospital.
Findings include:
1. The policy titled "Fall Prevention (revised 12/06/2021) was reviewed on 09/30/2022 at approximately 10:15 AM. The policy stated, "Fall Risk Assessment Score greater than or equal to 8 (High Risk)... Universal Fall Prevention Standards Plus.. Place yellow ID band on patient wrist, Place a bell sign on patient's door.... Use alarms and place a bell sign to communicate alarm in use."
2. An observational tour was conducted on the 8 East Medical/ Surgical with the Patient Care Manager (E #2) at approximately 11:30 AM. The following was noted:
Room # 804 (Pt # 8) no bell signage on the door and the bed alarm was off.
Room 810 (Pt #9) no bell signage on the door.
Room 820 (Pt #10) bed alarm was off.
An interview was conducted with E #2 during the observations. E #2 confirmed the above and stated "(Pt #8, Pt #9, and Pt #10) had fall risk scores equal or greater than 8 and should have been on high fall risk interventions. The patients did not have the fall interventions in place and should have."
3. An observational tour was conducted on 4th floor Rehab Unit with Patient Care Manager (E #3) at approximately 11:40 AM. Pt # 5, Pt #6, Pt #7 did not have yellow fall risk bracelet on. An interview was conducted during the observations. E #3 agreed that Pt #5, Pt #6 and Pt #7 were on high fall risk precautions, did not have the yellow fall bracelets on and they should have.
4. An observational tour was conducted in ICU with the Director of Nursing Practice and Operations (E #4) at approximately 11:50 AM. Room 210 (Pt #2) was observed in bed without the bed alarm on. E #4 confirmed the bed alarm was not on. An interview was conducted with ICU RN (E #5) during the tour. E #5 stated "If the fall risk is equal to or greater than 8, which is all of our ICU patients. The pt should have fall precautions including a bed alarm. The bed alarm should be on even if there's a sitter in the room."