HospitalInspections.org

Based on interview and record review the facility staff failed to follow facility policies and procedures for one of 13 sampled patients after Patient number 11 fell. This failure created the potential for missing recognition of fall related injuries, delayed treatment of injuries, additional falls, increased pain and suffering.

Findings:
On 5/27/24 Patient 11 (P11) was admitted to the facility for Kidney Pain. P11 was treated in the Emergency Department (ED) and transferred to the Surgery Recovery Room (SRR) to await a urinary system procedure. While waiting for the procedure in the SRR P11 had an unwitnessed fall.

On 7/11/2024 at 9:30 AM, during a concurrent interview and record review with the Director of Performance Improvement (DPI), the DPI stated, "It (P11's fall) should be on an incident form if anything else." An incident form was located, and the DPI arranged interviews with staff that provided P11 care around the time of the fall. The DPI provided a copy of the "Post Fall Assessment/Injury Prevention Huddle" and the facility policy titled, "Falls Reduction/Injury Prevention." The DPI confirmed the policy refers to completion of the "Post Fall Assessment/Injury Prevention Huddle" which was not done.

On 7/11/2024 at 10:00 AM, during a concurrent interview and record review with a Recovery Room Registered Nurse (RN9), RN9 stated, "He was in bed and called me over wanting to go to the bathroom to pee ... I told him that he couldn't get up and that I would go him a urinal. I did and gave it to him and made sure he had the call light then pulled the curtain for his privacy. ...it was taking some time ...I went over to check and asked if he was ok. He said 'yes' and that he was still trying. I went back to the desk and then he is calling help help and is on the floor.

RN9 was provided with a copy of a one-page facility document titled "Post Fall Assessment/Injury Prevention Huddle" having three pages of attachment. RN9 was given time to review the document and attachments to her satisfaction. When questioned RN9 was not aware of the document, attachments nor the requirement of completing the documentation after an incident such as this. RN9 stated she, "did not know about the forms." The "Post Fall Assessment/Injury Prevention Huddle" was not completed as required by the facility policy titled, "Falls Reduction/Injury Prevention."

On 7/11/2024 at 11:00 AM, during a concurrent interview and record review with a Recovery Room Registered Nurse (RN10), RN10 stated, "He was an easy recovery. He didn't complain of any pain the entire time. I heard he fell and that he got up on his own. I told him that he couldn't get up and he was totally compliant. He didn't try." RN10 delivered P11 to the orthopedics unit after recovery. RN10 stated, "I took him to the floor, ortho and gave him to the nurse there. I did tell her in report that he had fallen but had no complaints. He never mentioned anything to me about pain from the fall."

RN10 was provided with a copy of a one-page facility document titled "Post Fall Assessment/Injury Prevention Huddle" having three pages of attachment. RN10 was given time to review the document and attachments to her satisfaction. When questioned RN10 was not aware of the document, attachments nor the requirement of completing the documentation after an incident such as this. RN10 responded to questioning stating, "I didn't see this form, no. I didn't know about it at all."