HospitalInspections.org

Based on document review and interview, the facility failed to ensure nursing staff documented fall risk assessments, fall prevention interventions and updated post fall prevention interventions for 1 of 5 patients with falls (Patient #1) and failed to answer a patient's call light per facility policy for 1 of 10 patients medical records reviewed. (Patient #1)

Findings include:

1. Facility policy titled "Fall Prevention" last approved 6/2022 indicated the following: "...III. Procedure: A. Fall Assessment/Prevention: 1. Assess adult patients for fall risk: a. On admission. b. Twice daily (suggested 0900 [hours] and 2100 [hours]). c. When a change in condition occurs. d. Following a fall occurrence..."

2. Facility policy titled "Managing Clinical Alarms" last approved on 2/2021 indicated the following: "...II. Definition of Terms...F. Non-critical alarms: Alarms on medical equipment designed to alert staff to the presence of non-life threatening condition which may require action depending on clinical situation...III. Procedure...E. Alarm Response...3. General expectations to alarm response is as follows unless specifically defined by departmental policy...b. Non-critical alarms: within 1-5 minutes (or as appropriate)..."

3. A review of the facility event log related to the 7 Medical Unit for the time period of 7/1/22 through 12/13/22 indicated Patient #1 had a fall on 7/14/22.

4. Review of patient #1's medical record indicated the following:

(A) The patient was admitted on 7/12/22 at 1:39 p.m. and discharged on 7/15/22 at 2:27 p.m.

(B) Patient #1's medical record indicated the patient had a fall on 7/14/22 at approximately at 3:00 a.m. A nurse's note dated 7/14/22 at 4:00 a.m. indicated Patient #1 had an unwitnessed fall approximately an hour ago and on assessment the patient had a new skin tear on his/her right forearm but otherwise his/her assessment was negative/within normal limits. A provider progress note dated 7/14/22 at 7:52 a.m. indicated overnight Patient #1 had tripped when getting off from the bed and had an unwitnessed fall.

Patient #1's medical record indicated fall risk assessments on the following dates and times:

(a.) On 7/12/22 at 2:02 p.m., a fall risk assessment score of 35, which indicated a moderate fall risk.
(b.) On 7/13/22 at 6:00 p.m., a fall risk assessment score of 35.
(c.) On 7/14/22 at 5:52 a.m., a post fall risk assessment score of 60, which indicated a high fall risk.
(d.) On 7/14/22 at 4:00 p.m., a fall risk assessment score of 60.

(C) The medical record lacked documentation of a fall risk assessment on 7/13/22 for day shift and on 7/15/22. The medical record lacked documentation of fall prevention interventions on 7/12/22 at 2:02 p.m. and on 7/14/22 at 5:52 a.m.

5. A review of a call light log for Patient #1 indicated on 7/14/22 at 3:10 a.m., the patient initiated his/her call light and it was answered on 7/14/22 at 3:53 a.m., the call log indicated it was a total of 43 minutes and 41 seconds before Patient #1's call light was answered.

6. During an interview with A4 (Nursing Director) on 12/14/22 at 9:45 a.m., he/she verified the call light log information for Patient #1. A4 verified that Patient #1 initiated his/her call light on 7/14/22 at 3:10 a.m. and it was not answered until 3:53 a.m., which was a total of 43 minutes and 41 seconds. A4 verified that the call light went out to N6 (Patient Care Technician), N7 (Registered Nurse/Nurse Lead) and was answered by N1 (Registered Nurse).

7. During an interview with A4 on 12/14/22 at 12:39 p.m., he/she verified the medical record information for Patient #1.