HospitalInspections.org

Based on document review, policy review, medical record review, and interview, the hospital failed to ensure patients received care in a safe setting for 1 of 3 (Patient #1) patients who sustained a fall with injury while being cared for by hospital staff.

The findings include:

Review of the facility's "Patient Fall Prevention," policy last revised 5/2/2022, revealed "...A patient fall is a sudden, unintentional descent, with or without sustained injury that results in the patient coming to a rest on the floor, or on or against some other surfaces, on another person, or on an object ...All patients will be evaluated for fall potential through completion of the appropriate Falls Risk Assessment. This will occur during the admission assessment process; initial, daily nursing assessment; at minimum of once per shift; following a change in medical condition and/or level of care; and post fall."

Review of the medical record revealed Patient #1 was admitted to the hospital on 11/22/2022 with diagnoses of Hypertension, Chronic Kidney Disease, Pneumonia, Atrial Fibrillation, Hemiplegia Following Cerebral Infarction, Gastrointestinal Hemorrhage, and Diabetes Mellitus.

Review of the Physician Order dated 11/22/2022, revealed "...Up as per Therapy ..."

Review of the History and Physical dated 11/22/2022, revealed "...presented to the emergency room with complaints of shortness of breath with associated malaise and fever as well as cough ...He even had falls and sustained facial abrasions. CT [computed tomography] scan of the head and cervical CT scan will [were] also done and negative..."

Review of the Fall Risk Assessment dated 11/22/222 at 7:54 PM, revealed "...Ambulatory aid: Crutches/cane/walker ...Gait/transferring: Weak ...Morse Fall Scale score and risk level: 75 - High Risk ...Active fall prevention interventions: Bed/chair alarm, low bed, assistive device ..."

Review of the OT [Occupational Therapy] ...Evaluation dated 11/23/2022, revealed "...Patient reports having many falls in the past 6 months and states he fell last night in the ER ...Based on clinical judgement, patient likely to need max [maximum] A [assistance] to complete bed mobility and additional transfers at this time due to safety. Patient likely to have some difficulty with balance due to weakness..."

Review of the Emergency Notes dated 11/22/2022 at 8:33 PM, revealed "...I attempted to get ambulatory O2 [oxygen] Sat [saturation], pt [patient] provided with walker, which is what he uses at home, pt unable to get up and walk around, states, "I feel too weak" pt lives alone and reports he usually gets around ok at home ..."

Review of the Emergency Notes dated 11/22/2022 at 8:57 PM, revealed "...Pt had unwitnessed fall. Found on floor, lac to head. Pt is on blood thinners, with assistance pt helped back into bed, MD Hayes to bedside, C collar applied, partial trauma activated..."

Review of the Problem List/A&P dated 12/3/2022, revealed "...Left Dorsal Hand Skin Tear ...From a fall ...Left hand xray showed no evidence of fracture..."

Review of the email by the Director of Emergency Services dated 11/28/2022, revealed "...I spoke with [Named RN #1] about the fall that [Named Patient #1] had on 11/22/2022. She stated that she was really sorry and that she would never do that again. She said that he had CHF [Congestive Heart Failure] and was actually getting some relief in his breathing by sitting up for a few minutes. She also stated that she had been told that he ambulated with a walker independently at home ...I coached her on the high risk assessment and what that meant. She agreed and knew that she should have not left him even for a minute to get help to help him ambulate ...I coached her on usage of the radio. She could have radioed for help..."

During a telephone interview with the Complainant on 12/14/2022 at 11:10 AM, she stated "...The doctor had ordered the nurse to ambulate him [Patient #1]. The nurse could not do that by herself so she left him sitting on the edge of the bed by himself instead of hitting the call light to get assistance or putting my father back to bed with the side rails raised ...The house supervisor called me to let me know about the fall and never said anything about the large skin tear on his hand ...She was unapologetic about my father falling and to me was very rude ...I requested a call back from the Hospital Administrator and have yet to hear back ...It was neglectful to leave my father unattended when he could not control his upper body..."

During an interview with Registered Nurse (RN) #1 on 12/14/2022 at 4:36 PM, she stated "...[Named Physician] requested I do an ambulatory saturation with the patient ...I spoke with the patient and asked him if he felt like he could ambulate with me in the room. He said he ambulated at home with a walker and sometimes without the walker so I brought a walker in with him and explained to him what I needed him to do ...I assisted him to stand and that was when he told me that he felt too weak to stand so he sat back down on the edge of the bed ...I asked him if he felt comfortable enough to sit on the side of the bed with the call light within reach and a side rail up so I could go get [Named Physician] to assist me. He was alert and oriented and told me that he could, so I left the room with him sitting on the side of the bed ...He was alone for no more than 5 minutes ...I think it was xray that was walking past the room and saw him on the floor ...I have regretted leaving him since..."