HospitalInspections.org

Based on document review, observation and interview it was determined for 5 of 5 (Pt. #s 1-5) patients identified as a fall risk on admission, the hospital failed to implement fall interventions per policy.

Findings include:

1. Hospital policy titled, "Fall Risk Assessment and Prevention (revised August 2012)" required, "D. All patients identified at "high risk" for falls should have... and the following "high risk" interventions implemented and documented: ...3. Indicator (maple leaf) of high risk status should be placed outside patient's room..."

2. A tour of the Diamond Headache Unit was conducted on 12/22/14 at 10:45 AM. The tour did not identify any patients on fall risk (i.e.: having the door labeled with a maple leaf as per policy).

3. A computer printout of all patients on fall risk was requested and 5 patients on the Diamond Headache unit were identified as high risk for fall.

4. The clinical record of Pt. #1 was reviewed on 12/22/14. Pt. #1 was a 34 year old female admitted on 12/12/14 with the diagnosis of chronic migraine. The initial nursing assessment identified Pt. #1 as a high fall risk. The fall reduction program was not implemented by placing the maple leaf on the patients door.

5. The clinical record of Pt. #2 was reviewed on 12/22/14. Pt. #2 was a 42 year old female admitted on 12/12/14 with the diagnosis of chronic migraine. The initial nursing assessment identified Pt. #2 as a high fall risk. The fall reduction program was not implemented by placing the maple leaf on the patients door.

6. The clinical record of Pt. #3 was reviewed on 12/22/14. Pt. #3 was a 42 year old female admitted on 12/15/14 with the diagnosis of chronic migraine. The initial nursing assessment identified Pt. #3 as a high fall risk. The fall reduction program was not implemented by placing the maple leaf on the patients door.

7. The clinical record of Pt. #4 was reviewed on 12/22/14. Pt. #4 was a 55 year old female admitted on 12/17/14 with the diagnosis of chronic migraine. The initial nursing assessment identified Pt. #4 as a high fall risk. The fall reduction program was not implemented by placing the maple leaf on the patients door.

8. The clinical record of Pt. #5 was reviewed on 12/22/14. Pt. #5 was a 37 year old female admitted on 12/9/14 with the diagnosis of chronic migraine. The initial nursing assessment identified Pt. #5 as a high fall risk. The fall reduction program was not implemented by placing the maple leaf on the patients door.

9. During an interview on 12/22/14 at 11:30 AM, the interim nurse manager stated, "there should be a maple leaf on the door of each patient identified as a fall risk."