HospitalInspections.org

Based on record reviews and interviews the facility failed to keep current a nursing plan of care for Fall Risk and failed to communicate the plan of care between the interdisciplinary team to ensure 1 of 3 sampled patients (#1's) fall risk is minimized.

The Findings Include:

Review of the clinical record revealed that patient #1 was admitted to the facility on 05/03/10
and underwent left Total Left Knee Arthroplasty (replacement) on the day of admission due to severe degenerative joint disease.

Anesthesia Record dated 05/03/10 documents the type of anesthesia used to perform the
patient ' s surgery was a spinal nerve block. This type of anesthesia can cause the patient to
have decreased sensation and weakness in the lower extremities placing the patient at high
risk for falls.

The Adult Shift Assessment performed on 05/03/10 by a licensed nurse confirmed the alert and oriented patient was at high risk for falls due to left knee surgery, unsteady gait and decreased mobility. Fall precautions were documented as follows: Signage (armband, chart and door), non-slip footwear, assist with mobility and activities of daily living (ADLs). The assessment also noted that the patient was obese with a Body Mass Index (BMI) of greater than (30), the patient had a left Femoral Intravenous (IV) line in position and a dry, intact dressing to the left knee surgical incision.

Record review also revealed that in addition to the spinal nerve block, the patient also
received a femoral nerve block by Anesthesia to assist with pain management. The femoral nerve block was administered via a femoral intravenous (IV) line that was placed in the resident's left groin. The cumulative effects of the anesthetic agents placed the patient at increased risk for falls. The block was administered until 05/06/10 until a physician order to discontinue it was noted on 05/06/10.

Physical Therapy Observed Initial Evaluation notes dated 05/04/10 document the patient
required maximum assistance with bed mobility, assist of (2) persons for sit to stand position,
edge of bed to rolling walker and transition to bedside chair with rolling walker. The physical
therapist (PT) noted the patient "buckled" on the left knee during the evaluation. The PT listed
the following patient problems identified during the evaluation: Decreased strength, balance,
range of motion, transfer skills, gait skills, bed mobility and increased pain. No documentation
was found to substantiate the PT reported the results of the evaluation and the problems
identified, and discussed the interventions or plan of care with the nurse caring for the patient.

Review of the nurse's notes dated 05/05/10 revealed the patient fell at approximately 12:45
PM, while being assisted by a Patient Care Assistant (PCA) to transfer to the bedside
commode. The notes documented the PCA stated that the patient's left knee gave in when he/she was almost on the commode. The patient fell on top of the PCA. The patient's account of the fall concurred with the PCA's account. A post fall assessment was completed and documented. The licensed nurse documented her observation of bleeding at the distal end of the patient's left knee surgical incision, complaints by the patient of left knee pain at the level of (2) on a scale of (0 to 10), and limited mobility of the left lower extremity. A neurological assessment of the patient was performed; no neurological deficits were documented. The patient's temperature, pulse, respirations, blood pressure and oxygen saturation were within normal range. The physician was notified; an order to apply steri strips to the distal end of the incision was obtained. The notes further document the patient will be monitored and assessed.

The record review also confirmed that within the 6 to 7 hours preceding the fall, the patient
received (2) narcotic medications (Percocet (2) tablets at 6:27 AM and Oxycontin 10 mgs at
9:57 AM). It is to be noted, side effects of these medications, such as dizziness, in addition
to the effects of anesthesia can place the patient at high risk for falls.

A post fall Xray ordered by the physician on 05/05/10 immediately after the patient fell
revealed the patient did not sustain a fracture. At 3:50 PM the patient complained of headache
and was given (2) Percocet tablets as ordered for the treatment of pain.

During an interview conducted with the Director of Surgical Services on 07/23/10 at 3:00 PM, the director confirmed the patient fell, as described in the nurses notes. The director was questioned regarding how the plan of care for the patient is conveyed to the PCA, to ensure that safe care is provided. The director stated during the verbal shift report the nurse should have informed the PCA. The director confirmed information about the patient ' s femoral nerve block should have been conveyed to the PCA. The PCA would then have known the patient
needed 2 persons to assist with transfer. The director further stated the RN had forgotten to
provide this information to the PCA. The director also stated that PT is usually consulted
regarding the amount of staff needed to transfer patients.

No documentation was found during the clinical record review to substantiate the nurse
discussed the patient's plan of care with PT regarding the amount of staff needed to assist
the patient with his/her transfer and mobility needs.

During an interview conducted with a PT on 07/23/10 at approximately 4:10 PM, to determine the procedure for reporting observations, interventions and the physical therapy plan of care for the patients, the PT stated, when patient #1 knees buckled during the evaluation and the patient was assessed as requiring (2) persons for mobility and transfer, she would have reported this to the nurse.

Review of the fall investigation and root cause analysis performed after the patient fell revealed the patient asked for a walker to be used during the transfer. The PCA transferred the
patient without the assistance of another staff member and without a walker, which resulted in
the patient falling. The analysis further revealed the nurse failed to provide the PCA with
crucial information regarding the femoral nerve block the patient was receiving, which caused
his/her left knee to be numb. The nurse also failed to provide the PCA with the plan of care
information regarding the amount of support needed to transfer the patient safely.

The record review revealed that a plan of care for fall risk was documented for the patient on
03/05/10. Although fall precaution interventions were noted on the plan of care (Bed in the
lowest position, call bell within reach and frequent rounds), crucial information about the
patient receiving a nerve block and the amount of staff needed to transfer the patient was not
documented on the patient's plan of care for fall risk.