HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 1 patient (Pt #1) who fell at the Hospital during a physical therapy session, the Hospital failed to ensure the therapist followed the physician's fall precaution orders.

Findings include:

1. On 9/10/18 at approximately 10:00 AM, the Hospital's policy titled, "Fall Prevention Program" (reviewed 8/9/18) was reviewed and included, "...Fall Screening Tool...The tool required for the hospital is the Morse Fall Risk Assessment...Scoring Guidelines: < [less than or equal to] 45 = standard precautions: > [greater than] 45 = Strict Fall Precautions..."

2. The clinical record of Pt. #1 was reviewed on 9/10/18. Pt. #1 was a 58 year old male, admitted on 7/25/18, with a diagnosis of CVA (cerebral vascular accident - stroke) requiring rehabilitation. The admission nursing assessment, dated 7/24/18, included that Pt. #1 had a Morse Fall Risk Assessment Score of 80 (high risk for fall - strict fall precautions).

The Physician's (MD#1 - Attending Physiatrist - rehabilitation physician) order, dated and timed 7/24/18 at 5:22 PM, required, "Fall Precautions ... Order details: Do Not Leave Alone in Bathroom/Bed Alarm [alarm that sounds when patient attempts to get out of bed]."

Pt #1's History and Physical by MD #1, dated and timed 7/24/18 at 5:54 PM, included, "Decreased functional mobility and self-care secondary to stroke ... Left sided weakness and numbness, left sided facial droop, headache, neck and back pain and left hemi (sided) neglect ... Patient also has dysphagia (difficulty swallowing) and dysarthria (slurred speech) ... Continue aggressive physical therapy, occupational therapy and speech therapy to help with ... general patient safety."

The nurse's (E#2 - nurse assigned to Pt #1 on 7/27/18 from 7:00 AM to 7:00 PM) progress note, dated 7/27/18 at 11:10 AM, included, "Post Fall Evaluation Comments: Date/Time of fall: 7/27/18 at 10:45 AM, unwitnessed, bathroom, no injury. ...This RN [Registered Nurse] was assisting another patient in another room when PT [Physical Therapist - E #1] yelled out that patient had fallen in the bathroom. [E #1] stepped out of the bathroom to plug in computer and [Pt #1] leaned forward to wipe bottom and fell on the floor. [Pt #1] stated he hit his head, but after he was back in bed and during post fall assessment patient denied hitting his head. This RN completed Neuro check [check level of consciousness, pupils, vital signs and extremity strength] and patient status has not changed."

The Physical Therapist's (E#1) note, dated and timed 7/27/18 at 12:10 PM, included, " ...[Pt #1] participated limited due to request to go back to room to use the toilet and lay back down ... Fell in bathroom, unwitnessed."

3. On 9/10/18 at approximately 2:00 PM, an interview was conducted with E #2 (RN). E#2 stated that, based on Pt. #1's behavior, left sided neglect (ignore) and falls level, E #2 would not have left Pt #1 alone in the bathroom.

4. On 9/10/18 at approximately 11:40 AM, an interview was conducted with MD#1 (Attending Physiatrist). MD#1 stated that Pt. #1 should not have been left alone in the bathroom because of his impulsiveness and inability to control the left side of his body.