HospitalInspections.org

The Hospital identified a census of 37 patients. Based on document review, record review, staff and family interview, the hospital failed to provide safe care to 1 of 20 sampled patients. (#1)

Findings include:

- Document review on 10/11/10 of the hospital's "Fall Prevention Program" directed hospital staff to immediately evaluate a patient after a fall, using the Abbreviated Morse Fall Scale. Place a fall alert band on the patient following an initial fall. The policy directed staff to document the fall information on the patient's Kardex and update the patient's plan of care. The fall program included two elements which consisted of "...A Post-fall physical assessment-progress notes with the facts, the results of the assessment and physician notification and any subsequent orders. B. Documentation-Post fall assessment-Occurrence report..."

Patient #1 medical record reviewed on 10/4/10, revealed the hospital admitted the patient on 8/20/10 secondary to a Cerebrovascular Accident with left hemiplegia. Physician admission orders included an order for fall precautions. The plan of care identified patient #1 as a Fall Risk and the hospital staff placed alarms on the patient's bed and chair. Patient #1's medical record lacked documentation of a fall, patient assessment, and physician notification after Licensed Practical Nurse Q picked patient #1 up after a fall.

Family member R interviewed on 10/5/10 at 7:42pm verified patient #1 informed them Licensed Practical Nurse Q picked them up off of the floor in the bathroom.

Licensed Practical Nurse Q interviewed on 10/8/10 at 6:55pm reported they picked up patient #1 from the bathroom floor after a fall from the toilet. Licensed Practical Nurse Q stated they completed an assessment of the patient, found no injury, and placed the patient in a wheelchair. Licensed Practical Nurse Q revealed they failed to document the fall in the nurses notes, failed to document completion of a post fall patient assessment, failed to report the fall to the charge nurse or the patient's physician, and failed to complete an fall occurrence report.

The Hospital identified a census of 37 patients. Based on document review, record review, staff and family interview, the hospital failed to keep 1 of 20 sampled patients free from neglect (neglect is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm.) (Patient #1).

Findings include:

- Patient #1's medical record reviewed on 10/4/10, revealed the hospital admitted the patient on 8/20/10 secondary to a Cerebrovascular Accident with left hemiplegia and flaccid left side. Physician admission orders included an order for fall precautions. The plan of care identified patient #1 as a Fall Risk and the hospital staff placed alarms on the patient's bed and chair.

Document review of the hospital's "Fall Prevention Program"on 10/11/10, directed staff to evaluate a patient after a fall with the Abbreviated Morse Fall Scale. Place a fall alert band on the patient, enter the fall information into the patient's Kardex, and update the patient's plan of care. The fall program included two elements which consisted of "...A Post-fall physical assessment-progress notes with the facts, the results of the assessment and physician notification and any subsequent orders. B. Documentation-Post fall assessment-Occurrence report..."

Family member R interviewed on 10/5/10 at 7:42pm reported patient #1 informed them Licensed Practical Nurse Q picked them up off of the floor in the bathroom.

Licensed Practical Nurse Q placed patient #1 in the bathroom during toileting and neglected to remain in the bathroom with the patient, who was diagnosed with hemiplegia on the left side of their body.

Licensed Practical Nurse Q, interviewed on 10/8/10 at 6:55pm reported they picked up patient #1 from the bathroom floor after a fall from the toilet. Licensed Practical Nurse Q failed to provide the Post-fall assessment required by the hospital including notifiying the nursing supervisor and the patient's physician of the fall. Patient #1 physician did not have the opportunity to order tests or further assessment to determine the extent of the patient's injuries after the fall.

The Hospital identified a census of 37 patients. Based on record review, document review, and interview the hospital failed to maintain a complete medical record for 1 of 20 sampled patients. (#1)

Findings include:

- Document review of the hospital's "Fall Prevention Program"on 10/11/10, directed staff to include in the medical record documentation of the patient's post fall physical assessment, progress notes stating the facts, results of the post fall physical assessment, and physician notification with any subsequent orders. A completed post fall assessment included comprehensive, detailed requirements for staff to follow.

Licensed Practical Nurse Q interviewed on 10/8/10 at 6:55pm reported they picked patient #1 up from the bathroom floor after a fall from the toilet and failed to document the incident.

The medical record lacked documentation of patient #1's fall. Licensed nurse Q verified they failed to document any information of this adverse event in the medical record and failed to complete an occurrence report to inform the hospital and physician of further assessment requirements for this patient. The medical record lacked documentation of the fall (occurring 9/20/10 or 9/21/10), patient assessment, physician notification, and change to the plan of care.