HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 4 (Pt #1 and Pt #3) clinical records reviewed for patients that had a fall occurrence, the Hospital failed to ensure fall precautions were in place as indicated.

Findings include:

1. The Hospital process entitled "Fall Prevention Program-Adult" (02/2015) was reviewed on 8/29/16 at approximately 10:30 AM and required, "...1. Conduct a fall risk assessment on admission, every shift and with a change in patient status. 2. Document fall risk assessment in the electronic medical record...High Risk...b. Precautions based on assessed needs: i. Bed and/or chair alarm..."

2. The clinical record for Pt #1 was reviewed on 8/29/16 at approximately 11:00 AM. Pt #1 was a 68 year old male admitted to the Hospital on 6/29/16 with a diagnosis of subdural hematoma. The nurse's (E #1's) fall risk assessment and interventions dated and timed 7/6/16 at .... included Pt #1 was a high risk for falls and a bed alarm was in place as a fall precaution. E #1's note dated and timed 7/6/16 at 6:06 PM included, "...1700 (5:00 PM) Pt found out of bed on floor. Pt states he thinks he bumped his head..."

3. The fall report for Pt #1's fall, dated 7/6/16, was reviewed on 8/29/16 at approximately 10:30 AM. The report was completed by E #1 and included, "Pt found on floor after falling out of bed. Left side rail not up...Fall safety precautions in place at time of fall? No..."

4. On 8/29/16 at approximately 1:15 PM, an interview was conducted with E #1. E #1 stated that she did not recall if a bed alarm was being used as a fall precaution intervention for Pt #1, but no bed alarm was in place at the time of the fall.

5. The clinical record of Pt. #3 was reviewed on 8/29/16 at approximately 10:00 AM. Pt. #3 was an 87 year old female admitted on 8/20/16 with the diagnosis of acute ischemia. The nursing falls assessments dated 8/25/16 through 8/27/16 included that Pt. #3 was a high risk for a fall. The interventions documented as being put in place included, "Bed alarm, family member to stay and physical therapy evaluation". A nurses note dated 8/27/16 at 8:13 AM included a fall that occurred at 3:51 AM.

6. The fall report for Pt. #3s fall dated 8/27/16 was reviewed on 8/29/16 at approximately 10:00 AM. The report included, "Found on floor - leaning against wall. No bed alarm in place".

7. During an interview with the Administrative Director (E #4) on 8/30/16 at approximately 2:30 PM, E #4 stated the fall precaution interventions should be followed.