HospitalInspections.org

Based on record review and interview, the facility failed to ensure the right to receive care in a safe setting, in that
one of one patient (patient #1) did not have a documented post fall assessment as required by facility policy.

Findings included:

Patient #1 was a 75-year-old female who was admitted to the facility on 05/02/2024 for left hip osteoarthritis. Patient #1 underwent a Left Total Hip Arthroplasty on 05/02/2024 and sustained a fall without injury on 05/03/2024 at 1:42 PM.

Record review of patient #1 medical record did not evidence an immediate post fall assessment was performed. Per facility policy a post fall assessment would include objective and factual information of the fall, vital signs, a physical assessment, and neuro checks.

Record review revealed a "MIDAS Edge Fall Risk Event" was not completed as required by facility policy.

During an interview with personnel #1 and personnel #2 on 09/16/2024 confirmed the above findings

Policy and Procedure titled Falls Prevention and Resources, USPI-PC-204-C, effective 10/17/2016, revised on 01/2024, " ...I. Post-Fall Management ...3. Complete Post-Fall Assessment and document the objective, Factual information in the medical record.4. Obtain vital signs, a physical assessment and neuro checks after every fall and following doctor orders ...5. Notification of fall: o physician (if not previously called) o patient's emergency contact o Midas EDGE (Trademark) Fall Risk Event. 6. Objective documentation in the medical record should include, but is not limited to: * description of the fall episode to include: -- witnesses to the fall (if any)- position in which the patient was found- assessment post-fall (changes in ROM, neuro status, etc.)- interventions initiated- persons notified - follow-up activities- did the patient attempt to break the fall? - was there a warning? - can the patient follow directions? - is there sensory impairment? - is the patient less than 24 hours post anesthesia? - was there a history of fracture? - was there a history/ diagnosis of osteoporosis? - were there harm risk factors in the clinician's judgment present prior to the fall?...8. Report the fall to the charge nurse and at shift reports. 9. Complete an Event Report.

Facility document titled Patient Rights & Responsibilities document ..." Your Rights ...You have the right to safe, respectful, and dignified care at all times ...As a patient, you have the right to Respectful and considerate care in a safe environment.

Policy and procedure titled "Assessment and Reassessment, PC-007-F, Effective 09/29/2014, revised 12/2023, " ...3. Assessment and Reassessment-Post Surgical Unit ...c. Any change in patient condition requires an immediate reassessment with changes in the interdisciplinary plan of care reflecting the change in condition. c. PSU ...PRN condition changes ... Neurovascular ...PRN condition changes ...Neurological ...PRN condition changes.