HospitalInspections.org

Based on clinical record review, interviews and document review it was determined the facility failed to conduct every one (1) hour safety rounds on one (1) out of thirty (30) patients (patient #1). This failure has the potential to place all patients at risk for violation of their rights for care in a safe setting, creating the potential for harm.

These are the findings:

1. A review of patient #1's clinical record revealed Registered Nurse (RN) #1 performed a fall risk assessment on 9/5/19 at 9:00 p.m. The Morse fall risk assessment placed patient #1 in the moderate fall risk category. RN #1 performed safety rounds, which included fall precautions rounds, on patient #1 on 9/5/19 at 11:00 p.m. RN #1 performed safety rounds on patient #1 on 9/6/19 at 1:00 a.m., 3:00 a.m. and 5:00 a.m. A review of patient #1's clinical record revealed after multiple attempts to get out of bed unassisted, she got out of bed unassisted and fell on 9/6/19 at 5:20 a.m. RN #2 found her in the floor in her room next to the bathroom. A review of patient #1's clinical record revealed the physician on-call was notified of the fall and on 9/6/19 at 5:29 a.m. he ordered an x-ray of patient #1's right hip. RN #1 did a post fall risk assessment and assigned patient #1 to the post-fall high risk category. The x-ray showed a subcapital femoral neck fracture of the right hip with mild superior displacement of the femoral shaft. In the orthopedist's operative procedure note, dictated on 9/6/19 at 8:08 p.m., he noted he performed a Stryker bipolar hemiarthroplasty after the fall. A review of patient #1's clinical record revealed the last surgical nurse's note was done at 6:56 p.m. The first safety round after patient #1 was returned to Five (5) Pavilion was performed by RN #2 on 9/6/19 at 8:00 p.m. RN #2 performed the next safety check at 12:11 a.m. on 9/7/19. No staff performed safety rounds on patient #1 again until 3:00 a.m. 9/7/19 at which time RN #2 began performing hourly safety rounds.

2. In an interview conducted with RN #1 on 10/15/19 at 10:00 a.m. he revealed patient #1 got out of bed multiple times during his 7:00 p.m. to 7:00 a.m. shift 9/5/19 to 9/6/19. He revealed he was able to redirect her to go back to bed and he met her needs each time the alarm sounded. RN #1 revealed he did not feel one-on-one observation was warranted at that point. He revealed he would not hesitate to call a physician for a one-on-one order if he felt it was needed.

3. In an interview conducted with RN #2 on 10/16/19 at 8:10 a.m., with the Five (5) Pavilion Nurse Manager, he revealed he felt the policy to conduct every one (1) hour safety rounds on a high fall risk patient after a fall was new and he was not aware of it. RN #2 stated he could not remember why he increased the safety rounds on patient #1 to every one (1) hour at 3:00 a.m. on 9/7/19. The Nurse Manager revealed the policy was not new but RN #1 may not have been familiar with it as he had only been off orientation for one (1) week at the time of the fall.

4. A review of a document titled Fall Prevention/Entrapment Plan, revised February 2019, revealed a patient on the Five (5) Pavilion unit who is a moderate fall risk is to have in part: "...Safety Round a minimum of every two hours." A review of the document revealed a patient who is post fall status is to have in part: "...Safety Rounds every hour or more frequently as indicated assessing personal needs."