HospitalInspections.org

A. Based on document review, observational tour, and interview, it was determined, for 3 of 10 clinical records reviewed (Pts. #2, 4, & 5) for patients requiring fall precautions, the hospital failed to ensure patients were protected from falls, according to policy.

Findings include:

1. On 9/16/13 at 11:30 AM, Hospital policy titled, "Fall Reduction Program", approved 5/28/13, was reviewed. The policy required, "Responsibilities: A. Registered Nurse... 1. Initial and ongoing assessment of fall risk factors... 2. Implementation of interventions for patients at high risk for falls... Patient Care Management: A. Fall risk assessment - 1. Patients will be assessed for fall risk... b. Once every shift... B. Fall prevention... 2. High risk fall precautions (for fall risk score 8 or greater): a. Apply yellow arm band, yellow booties, and yellow magnet on the door frame..."

2. On 9/16/13 between 9:45 AM and 11:20 AM, an observational tour was conducted with the Nurse Manager on the 6 West (telemetry) unit. At 10:00 AM, a patient (Pt. #2) was sitting on the side of the bed in room 613-2 and a portable commode was near her. Pt. #2 stated that she had gout in her right foot and needed assistance to transfer to the portable commode. Pt. #2 did not have on a yellow arm band, yellow booties, and a yellow magnet was not on the door frame."

3. On 9/16/13 at 11:05 AM, Pt. #2's clinical record was reviewed. Pt. #2 was an 82 year old female, admitted on 9/13/13, for chest pain. Pt. #2's fall precaution assessment dated 9/16/13 at 9:01 AM included a score of 4, not placing Pt. #2 at high fall risk. However, the assessment did not include Pt. #2's inability to get to the commode (3 points) or ambulate independently (1 point), which would have raised the fall risk score to 8, requiring high fall risk precautions.

4. At 10:20 AM, a patient (Pt. #4) was lying in bed in room 679-1. Pt. #1 was not wearing a yellow armband, the required yellow magnet was not on the door frame, and Pt. #4 did not have on yellow booties.

5. On 9/16/13 at 10:35 AM, Pt. #4's clinical record was reviewed. Pt. #4 was an 80 year old male, admitted on 9/3/13, for general weakness, mental status, atrial fibrillation, and urinary tract infection. Pt. #4's fall precaution assessment dated 9/16/13 at 8:30 AM, included a score of 20, indicating high fall risk. Not all required fall risk precautions were in place for Pt #4.

6. At 10:25 AM, a patient (Pt. #5) was lying in bed in room 683. A yellow magnet was on the door frame. However, Pt. #5 was not wearing yellow booties or a yellow arm band.

7. On 9/16/13 at 11:10 AM, Pt. #5's clinical record was reviewed. Pt. #5 was a 79 year old female, admitted on 9/10/13, for bradydysrhythmia and near syncopal episode. Pt. #4's fall precaution assessment dated 9/16/13 at 8:00 AM, included a score of 12, indicating high fall risk. Not all required fall risk precautions were in place for Pt #5.

8. On 9/16/13, between 9:45 AM and 11:20 AM, an ongoing interview was conducted with the Nurse Manager during the observational tour of 6 East and the clinical record review. The Nurse Manager made the same observations and clinical record findings as the Surveyor and agreed that all required fall risk precautions were not in place for Pts. 2, 4, & 5.

B. Based on document review and interview, it was determined, for 1 of 5 patients (Pt. #8) who fell in the hospital, the hospital failed to ensure patients who fell were provided post fall care, according to policy.

Findings include:

1. On 9/16/13 at 11:30 AM, Hospital policy titled, "Fall Reduction Program", approved 5/28/13, was reviewed. The policy required, "D. Assessment and treatment of fall-related injuries: If a patient fall occurs, immediately post-fall: 1. Assess mental/physical status... 5. Notify the physician/provider. 6. Notify the family immediately..."

2. On 9/17/13 at 12:45 PM, Pt. #8's clinical record was reviewed. Pt. #8 was an 31 year old female, admitted on 8/21/13, for sore throat and weakness. Pt. #8's fall risk score was 2 (not at risk) on 8/22/13 at 8:00 AM. The fall huddle report dated 8/22/13 at 10:40 AM, included Pt. #8 fell at 10:29 AM and "Patient stated she was walking to bathroom and just fell, did not trip or slip." No progress notes were found after the fall to indicate Pt. #8 was assessed, the doctor was notified, and Pt. #8's relatives were notified.

3. On 9/17/13, at 1:30 PM, an interview was conducted with the Director of Quality, Patient Safety, and Regulatory Compliance. The Director stated that the information regarding notification of the doctor and relatives of Pt. #8's fall was not in the clinical record, but was in the incident report.