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Based on medical record review and staff interview, the hospital failed to analyze the falls in 2 of 2 records reviewed (Pt #1 and #2) out of a total of 17 sampled records.

Findings include:

Per surveyor #03383:

1) Medical record review on 11/8/10 revealed that Patient #1 was hospitalized on 11/17/09 to undergo a left total knee arthroplasty. Pt #1 had a genital to femoral nerve block placed on the left side. According to Risk Manager X on 11/8/10, Pt #1 fell between 6 PM and 7 PM on 11/17/09. Pt #1 was on anticoagulation therapy (blood thinner) to prevent deep vein thrombosis. Pt #1 developed a hematoma on his right buttock after the fall. CNA R reported to RN BB that Pt #1 was assisted to the floor and the case was handled as if the patient was lowered to the floor. Pt #1 indicated during an interview on 11/11/10 at 11:19 AM that he spoke to the Patient Relations Administrator and told her what actually happened to dispute the story given by CNA R. VP F indicated on 11/16/10 at 1:06 PM during a phone conference that a root cause analysis was not done on this record because Pt #1 was lowered to the floor and this was not considered a fall. Despite discrepancies of whether Pt #1 fell to the floor or was lowered to the floor, the hospital failed to conduct an in-depth analysis to determine if Pt #1 received care based on hospital policies and procedures and standards of practice.

2) An interview with Patient Transporter (PT) O on 11/3/10 at 2:10 PM . PT O indicates she transported Pt #2 to his appointment at St. Luke's Medical Center on 5/21/10. PT O asked Pt #2 to switch wheelchairs after he arrived in his wheelchair without foot pedals. Pt #2 declined and indicated he would lift is legs during transport. Pt #2 fell out of the chair on a section of the floor with a metal divider. Pt #2 fell forward onto the floor. He was asked if he wanted to go to the emergency room (ER). He fell on his knees. Someone took his statement. There is a seam in the floor. PT O took him to hyperbaric and he told staff that he fell. PT P arrived about that time. A nurse filled out an incident report. After the interview with PT O on 11/3/10 at 2:25 PM, PT O PT P, VP A, and Surveyor #03383 walked over to where the fall occurred. VP A indicated at that time that no follow-up was done to determine the cause of the fall.

Based on one of one staff e-mail (F), and a review of Quality/Safety Council meeting minutes, the hospital failed to implement fall huddles as indicated by the Quality Council in July 2010.

Findings include:

Per review of Quality Council meeting minutes conducted on 11/16/10 at 4:00 PM by Surveyor #03383:

July 2010 meeting minutes under the Patient Safety-Patient Falls Prevention Section show RN II reviewed with the Council the Patient Safety PDSA (Plan-Do-Study-Act) for patient falls. Each department was required to do a PDSA. The aim of the PDSA was to increase staff awareness and reduce patient falls to zero. All of the falls data will be reviewed quarterly. Fall huddles (staff meetings to discuss fall) implementation after fall occurs. All departments have their own action plan in place and fall huddles are conducted after a fall has occurred. The action section indicates patient falls will be reviewed by the Quality/Safety Council quarterly through risk management reports. Quality/Safety Council meeting minutes for August, September, and October 2010 fail to show falls were discussed.

VP Nurse Executive F e-mailed a Fall Huddles form to Surveyor 03383 on 11/15/10 at 5:09 PM and indicated the tool was developed last week by the Clinical Nurse Specialist, Patient Care Manager and the Chair of the 4C Unit Council. Fall Huddles implementation was discussed in July; however, based on the e-mail, staff did not act on implementing fall huddles procedures until the complaint investigation began on 11/8/10 at the Sinai Campus.

Based on one of one staff interview (Y), staff e-mail and a review of Quality/Safety Council meeting minutes, the hospital failed to continue to track improvements of the fall reduction program to ensure successful improvements are sustained over time.

Findings include:

Per Surveyor #03383:

Educator Y was interviewed on 11/8/10 at 11:19 AM and revealed that a PDSA (Plan-Do-Study-Act) for fall prevention was implemented in 2008 for patient that had a femoral nerve block after a total knee replacement.

The PDSA project entitled, Fall Prevention for patients with an Infusing Femoral Nerve Block after Total Knee Replacement was reviewed on 11/8/10 at 12:30 PM and shows the PDSA was completed on the 4 Center Orthopedic floor 6/30/2009. Data was collected Jan 2008 through Jun 2009. Data shows 2 falls in the first quarter (Jan, Feb, Mar), 2 falls in the second quarter (Apr, May, Jun), 4 falls in third quarter (Jul, Aug, Sept), and 1 fall in fourth quarter (Oct, Nov, Dec) of 2008. The data shows 2 patient falls for the first quarter (Jan, Feb, Mar) in 2009 and no falls in the second quarter (Apr, May, Jun) of 2009. The project was completed 6/30/2009. PDSA actions indicate a gait belt and a knee immobilizer should be placed on the affected leg when ambulating and always have two people available for all transfers and ambulation while block is in affect. CNA Q and CNA R failed to use a gait belt or knee immobilizer on Pt #1 that resulted in a fall on 11/17/09 (Reference A287)

Per review of Quality Council meeting minutes conducted on 11/16/10 at 4:00 PM by Surveyor #03383:

July 2010 meeting minutes under the Patient Safety-Patient Falls Prevention Section show RN II reviewed with the Council the Patient Safety PDSA (Plan-Do-Study-Act) for patient falls. Each department was required to do a PDSA. The aim of the PDSA was to increase staff awareness and reduce patient falls to zero. All of the falls data will be reviewed quarterly. Fall huddles implementation after fall occurs. All departments have their own action plan in place and fall huddles are conducted after a fall has occurred. The action section indicates patient falls will be reviewed by the Quality/Safety Council quarterly through risk management reports. Quality/Safety Council meeting minutes for August, September, and October 2010 fail to show falls were discussed.

VP Nurse Executive F e-mailed a Fall Huddles form to Surveyor 03383 on 11/15/10 at 5:09 PM and indicated the tool was developed last week by the Clinical Nurse Specialist, Patient Care Manager and the Chair of the 4C Unit Council. Fall Huddles implementation was discussed in July; however, based on the e-mail, staff did not act on implementing fall huddles procedures until the complaint investigation began on 11/8/10 at the Sinai Campus. A current PDSA for 2010 was not provided.

A review of Quality/Safety Council meeting minutes for the past year revealed the following:

Nov 2009: A goal was set to reduce falls by 50%. A system-wide falls group was put in place to work on fall reduction.

Dec 2009: Falls reviewed for first, second, and third quarter. Action indicates each nursing unit has established an action plan to reduce falls and a system-wide falls group is in place.

Jan 2010: Falls not discussed.

Feb 2010: All four quarters of 2009 falls data reviewed. Falls continue to increase with 4th quarter showing the highest. Action shows system-wide falls group in place to work on fall reduction system-wide. Does not indicate specifics of what the group is doing to reduce falls.

Mar 2010: Falls not discussed.

April 2010: Falls not discussed.

May 2010: Falls decreased on med/surg unit; however increased on rehab unit. Actions indicate each nursing unit has established an action plan to reduce falls and a system-wide falls group is in place.

June 2010: Falls not discussed.

July 2010: PDSA (plan-do-study-act) for falls implemented on each unit with goal of reducing patient falls to zero. Falls data will be reviewed quarterly. Fall huddles implementation after fall occurs.

Aug 2010: Falls not discussed.

Sept 2010: Falls not discussed.

Oct 2010: Falls not discussed.

The Quality/Safety Council is not meeting quarterly per schedule and failed to ensure staff follow through on July 2010 PDSA and fall huddles to ensure staff sustain the goal of zero patient falls.

Based on medical record review and staff interview, staff failed to adhere to hospital policies and procedures or PDSA (Plan-Do-Study-Act) recommendations in 1 of 2 of patient falls (Pt #1) reviewed out of a total of 17 sampled records. Staff also failed to implement a fall prevention care plan until 2 days after admission for in 1 of 7 patients (Pt #14) identified as a high fall risk in 17 sampled patients.

Findings include:

Per Surveyor #03383:

Fall Prevention Policy No: 1002:
Defines an assisted fall as a fall in which any staff member (whether nursing service employee or not) was with the patient and attempted to minimize the impact of the patient's descent to the floor or in some manner attempting to break the patient's falls.
Re-evaluate the patient's fall risk after the patient has surgery or procedure requiring sedation, after a room change, when the patient demonstrates a change in condition (e.g. altered mental status, elimination, mobility, etc.) or a change is noted in any of fall risk variables on the Morse Fall Scale.
For patients who fall during their hospitalization, re-evaluate fall risk and initiate or revise fall prevention plan of care to address circumstances associated with the fall as appropriate.
Table 2 of the policy entitled, Interventions to reduce Fall Risk indicates for patients with altered mobility: Use gait belt, mobilize (early and progressive ambulation unless contraindicated), collaborate with physical therapy, and minimize distraction.

Post-Fall Management Policy No: 1003:
Procedure indicates immediately after a fall occurs before the patient is moved, the RN conducts an initial focused post-fall patient assessment including:

Assess for obvious injury or pain:
? Head or tenderness
? Neck pain or tenderness
? Thorax/chest/abdomen
? Hip/groin/pelvis or leg
? Other

Neurologic Assessment:
? Standard assessment including level of consciousness, pupils, extremity movement*, speech/verbalization, sensation, swallow quality, memory/amnesia, orientation, cognition and paresthesia*
? Glasgow Coma Scale
? Presence of symptoms of neurologic deterioration associated with increasing intracranial pressure including GCS < 15*, change in behavior, severe or increasing headache or persistent vomiting

Vital Signs:
? Heart Rate
? Blood Pressure
? Respiratory rate

Consider additional assessments based on patient symptoms:
? Telemetry
? Physical Examination
? Pulse oximetry
? Blood sugar check

Notify the physician (Attending or Hospitalist) immediately:
? Report actual or potential injury especially if head/neck injury is observed, reported, or suspected.
o If radiology testing is requested, order STAT (immediately) and specify reason as " Acute Fall. "
? Report history of osteoporosis, bleeding disorders and/or use of anticoagulation agents including Warfarin, Heparin, Enoxaparin, or antiplatelet agents.

Note: If patient is receiving anticoagulant medication collaborate with physician regarding the need for laboratory testing or if holding medication is appropriate.

PDSA project completed on June 2009 for total knee replacement patients who receive a femoral nerve block indicate a gait belt and a knee immobilizer on the affected leg should be used when ambulating and always have two people available for all transfers and ambulation while block is in affect.

Per record review and staff interview:

1) Record review conducted on 11/8/10 at 8:45 AM and 11/15/10 7:00 AM revealed Pt #1 was hospitalized on 11/17/09 to undergo a left total knee arthroplasty. Pt #1 had a genital to femoral nerve block placed on the left side. In an interview with Patient Care Manager I and Risk Manager X on 11/8/10 at 9:00 AM, it was stated that Pt #1 was lowered to the floor between 6 PM and 7 PM on 11/17/09. Pt #1 was on anticoagulation therapy (blood thinner) to prevent deep vein thrombosis. The record shows Pt #1 developed a noticeable hematoma on his right buttock after the fall/lowering on 11/20/10. An x-ray of the left leg and lab tests were not ordered until 11/19/09, two days after the falling incident occurred.

The physician orders show a knee immobilizer was not ordered until 11/18/09. On 11/19/09 at 5:50 PM Lovenox was changed to 30 mg subq daily. An x-ray was ordered on 11/19/09 at 7:00 PM for post-op fall. A CT scan of abdomen and pelvis without contrast was ordered stat (immediately) on 11/20/09 at 4:15 PM to rule out (r/o) bleeding.

Documentation in the Daily Physical Assessments (Nursing) on 11/17/09 does not show this incident with Pt #1 lowered to the floor or fell. The record does not reflect an nursing assessment was completed after the fall occurred. The record does show Pt #1 had a change in condition when he became tachycardic (rapid heart rate) on 11/18/09 beginning at 3:00 AM. Pt #1 is described as lethargic and tachycardic on 11/19/09 beginning at 5:00 PM. Documentation about complaints of right buttock pain began on 11/20/09 at 9:00 AM when Pt #1 indicated the pain in right buttock hurts worse than left knee.

Labs results on 11/17/09 at 6:40 PM show Hgb 11.8 (range 13.0-17.0) and Hct 33.3 (range 39.0-51.0). On 11/19/09 at 6:20 AM Hgb dropped to is 8.8 and Hct dropped to 25.0; and at 4:35 PM Hgb is 9.1 and Hct is 25.7. On 11/20/09 at 8:30 AM, Hgb dropped to 7.9 and Hct dropped to 22.3; and platelets was 75 (range 140-450); at 3:00 PM Hgb continues drop to 7.0 and Hct is 19.9. Pt #1 received 2 units of PRBCs.

Per Interview with CNA R on 11/10/10 at 4:11 PM:
"Pt had knee surgery and a block. Put a knee immobilizer on him. Wanted to urinate ...placed on side of the bed. The RN knew patient would be standing at bedside to urinate. He asked CNA Q to step out. Let the nurse know (RN BB). The patient didn't want a female in the room. All at once his knee gave out buckling ...eased him down to floor. He was bigger than me. When his knee buckled (surgical knee) I eased him down to the floor. It happened so fast. I broke his fall ...I eased him down ...he went down. It happened so fast that I was kind of stunned. We were both stunned. I informed the nurse ...they did x-rays and informed the doctor ...I think it was Dr. EE ...did all sorts of tests to make sure nothing is broke. Pt Care Manager I did talk to us. What happened and explained to them. Do not ever leave a patient whether they want one person or not. Use a gait belt for surgery I think we did have a gait belt on."

Per interview on 11/11/10 at 3:00 PM with RN BB:
"I was aware that Pt #1 needed to get up because he was having trouble urinating. I told them (CNA Q and CNA R) that someone has to be with Pt #1. The CNA's knew there should be at least 2 people. I did not see the way Pt #1 was positioned on the floor because he was on the bed when I arrived. The way the incident was described to me I did not check things out. Pt #1 asked the female assistant to step out of the room for privacy and CNA R held on to the patient. I asked the patient if he hit his head and he said no. I'm sure I examined him. I don't remember because I am going by what the nursing assistant told me. I do remember calling the doctor and described it the way the aide explained it to me. I didn't see what happened. I checked his leg. I don't recall which leg. I don't remember if an immobilizer was on his leg. CNA R told me that Pt #1 didn't fall."


Per statement provided via e-mail by Vice President/Nurse Executive F on 11/17/10 at 10:55 AM:
"Since the patient was not ambulating, merely standing at the bedside, neither a gait belt nor a knee immobilizer was used. During the time the patient was standing, his legs buckled and he was assisted to the floor by the male CNA, suffered bruising on R buttock. Patient was assisted back to his bed by the 2 CNAs; RN completed the post fall assessment and notified the physician of the fall."

VP F indicated on 11/16/10 at 1:06 PM during a phone conference that a root cause analysis was not done on this record because Pt #1 was lowered to the floor and this was not considered a fall. Pt Care Manager I indicates an assisted fall is considered a fall. Despite discrepancies of whether Pt #1 fell to the floor or was lowered to the floor, CNA Q, CNA R, and RN BB failed to follow the hospital's Fall prevention and Post-Fall Management policies to ensure Pt #1 received care based on evidence-based practice.

CNA Q and CNA R failed to follow hospital policy when a gait belt or knee immobilizer was not used when Pt #1 stood to urinate on 11/17/09 and fell. CNA Q and CNA R also failed to follow hospital policy when they placed Pt #1 back into bed before RN BB arrived to observe Pt #1's positioning on the floor and to assess Pt #1 for injuries. Documentation fails to show RN BB conducted an RN assessment based on the Post-Fall Management policy.

CNA S was interviewed on 11/8/10 at 10:30 on unit 4 Center to determine whether training she received was effective to prevent another incident like this from reoccurring. CNA S was asked what she would do if she and another CNA had to get a patient up for toileting and the patient asked her to step out of the room. CNA indicated: I would stay in the room on the other side of the curtain. (Not per training or policy)

2) A review of Pt #14's electronic medical record with the assistance of VP F, Pt Care Manager I, and Clinical Nurse Specialist J on 11/8/10 at 10:15 AM shows Pt #14 was admitted to the hospital in acute renal failure on 11/6/10. A Morse Fall Risk assessment conducted at 9:00 AM on 11/6/10 reveals Pt #14 is at high risk for falls with a score of 85 (Morse score greater than 45 is high risk). A fall risk care plan was not initiated for Pt #14 until 11/8/10 at 7:00 AM, nearly 2 days later.