HospitalInspections.org

Based on policy review, medical record review, and interview, nursing staff did not implement fall prevention measures for Patient #1 in accordance with facility policy.

Findings Include:

Review of policy "Fall Management and Safety Protocol" last revised 04/2021 revealed staff are to assess and periodically re-assess each patient's risk for falling. Re-assess patients each 12-hour shift and following a fall or change in position. Post a red fire alarm sign on inside of door as a reminder to re-set Bed-Check (bed alarm system) on moderate to high-risk patients. If a fall occurs, document the change in condition. Calculate fall risk score. If there is a history of falling, immediate or within past 3 months, increase the score by 25 points.

Medical record review on 10/15/21 for Patient #1 from 06/18/21 through 06/20/21 revealed the following:
-Fall Risk Assessment and Fall Prevention assessments were performed on every shift with Fall Risk Score of (75) for Patient #1, who is a high risk for fall. Fall Risk interventions in the nursing documentation included education, non-skid slippers, reinforce call bell use, frequent reorientation, fall alert ID/band on patient, fall alert outside room, bed alarm, place patient near the nurses' station, and universal fall precautions.

-On 06/21/21 at 01:55 AM, nursing note stated "Patient #1 rolled out of bed. A two-person assistance was required to get Patient #1 back to bed. There is no documentation to indicate nursing staff re-assessed Patient #1's Fall Risk Score after he experienced the fall at 01:55 AM.

-On 06/21/21 at 09:00 AM, a Fall/Safety Assessment was completed indicating that Patient #1 has not fallen within the last 3 months despite experiencing a fall on 06/21/21 at 01:55 AM.

-On 06/21/21 at 10:25 PM, Patient #1 was found on the floor by an aide who reported Patient #1 was "getting up to go to bathroom." No documentation was found in the medical record indicating a bed alarm was implemented on 06/21/21 at 09:00 AM when the last Fall/Safety Assessment was performed.

Interview on 10/15/21 at 10:30 AM with Staff (A), Chief Nursing Officer, verified these findings.

Based on medical record review, policy review, and interview the nursing staff did not document patient hygiene, safety and positioning needs in accordance with the nursing plan for 3 of 9 patients (Patient #2, 4 and 5).

Findings Include:

Review of the medical record from 10/07/21 to10/14/21 for Patient #2 revealed a diagnosis of altered mental status with acute metabolic encephalopathy, requires two people to assist with bathing, requires total assistance with oral care, and is at a high risk for falls. There is no documentation for bathing or oral care on 10/09/21, 10/10/21, 10/11/21 and 10/13/21.

Review of the medical record for Patient #4 revealed a diagnosis of post-surgical knee surgery and acute metabolic encephalopathy. Patient #4 requires assistance from other persons with bed mobility (rolling to both sides in the bed), bathing/oral care, and is a high risk for falls and a moderate risk for skin pressure injury. No documentation was found to indicate Patient #4 received bathing, oral care and/or turning and positioning from 10/13/21 at 06:04 PM to 10/14/21 at 12:00 PM.

Review of the medical record from 10/12/21 to 10/15/21 for Patient #5 revealed documentation of decreased alertness and attention to safety concerns, requires assistance from other persons with bed mobility (rolling from side to side) and bathing/hygiene, is at a high risk for falls, and at risk for skin pressure injury. The only documentation for bathing/hygiene during this timeframe was on 10/14/21.

Review of policy "Nursing Model of Care" revised 06/19/20 revealed patient baths are scheduled from 07:50 AM to 12:00 PM. Evening bathing and oral care is scheduled from 08:30 PM to 11:00PM. Document findings.

Review of policy "Nursing Model of Care" revised 06/19/2020 revealed patients are turned and positioned every 2 hours.

Interview on 10/15/21 at 10:30 AM with Staff O, RN Clinical Educator Supervisor verified these findings.

Based on medical record review, policy review, and interview, medical staff did not document an assessment after Patient #1 experienced a fall on 06/21/21 at 01:55 AM.

Findings Include:

Review on 10/15/21 of nursing documentation dated 06/21/21 at 01:55 AM revealed Patient #1 experienced a fall, rolling out of bed. Nursing staff performed an assessment and notified the Medical Provider and family. No evidence was found in the medical record to indicate that the Medical Provider documented a post fall assessment for Patient #1.

Review on 10/15/21 of the Medical Staff "Rules and Regulations" last revised 04/18/18 revealed the Attending Physician will be responsible for the medical care and treatment of each patient in the hospital and the prompt, complete, and accurate preparation of the medical record. The Attending Practitioner will record a progress note at the time of each patient encounter on all hospitalized patients.

Interview on 10/15/21 at 10:00 AM with Staff (U), RN, revealed that the Attending Physician was notified of Patient #1 fall on 06/21/21 at 01:55 AM, came to Patient # 1's room, and performed an assessment. Staff (U), RN was unsure if the Attending Physician documented an assessment.

Interview on 10/15/21 at 10:30 AM with Staff (A), Chief Nursing Officer, verified these findings.