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Based on documentation review the Hospital (Hospital #1) failed to ensure that patient falls were thoroughly analyzed.

Findings included:

The Incident Report Log for the period of 6/1/10 to 12/10/10 was reviewed and 6 incidents identified related to use of the tub/shower/bathrooms were selected for focused review (Patients #2, #3, #4, #5, and #6). The review determined that 2 of 6 incidents (Patients #2 and #3) were related to slipping in the shower.

Patient #2:
On 11/3/10 Patient #2 slipped exiting the wet shower resulting in a laceration to a finger.

Patient #3:
On 10/15/10 Patient #3 reported slipping in the shower hitting the head and elbow. Radiology tests were negative. Documentation indicated that the shower area was cleaned.

Review of the incident reports indicated that there was no documented follow-up to indicate that environmental factors were analyzed to determine if there were any changes that could be made to improve patient safety.

During a tour of Hospital #1's second floor, conducted on 12/10/10 with the Treatment Director present, the surface of the tub and several of the showers were inspected. The surfaces felt were smooth to touch. During the survey Hospital #1 contacted a company that resurfaced tubs and showers.

Based on documentation review Hospital #1 failed to ensure that fall assessment were completed per policy for 6 of 11 applicable patients (Patients #1, #2, #3, #4, #6, and #9).

Findings included:

Review of the Policy/Procedure titled Fall/Accident Prevention indicated that that falls assessments were to be completed upon admission, at 4:00 P.M. the day of admission (as appropriate), the day after admission, after a fall, and as condition warrants.

Medical record review and review of incident reports determined the following:

Patient #1:
Patient #1 was admitted to Hospital #1 on 9/25/10 at 4:16 P.M.

Patient #1 was assessed for fall risk upon admission but was not reassessed on the day after admission.

Patient #2:
Patient #2 was admitted to Hospital #1 on 10/31/10 at approximately 6:00 P.M. Patient #2 had falls on 11/3/10 and 11/8/10.

Patient #2 was assessed for fall risk upon admission and the day after admission but was not reassessed after falls on 11/3/10 and 11/8/10.

####Patient #3:
Patient #3 was admitted to Hospital #1 on 10/10/10 at approximately 3:30 P.M. Patient #3 fell on 10/15/10.

Patient #3 was assessed for fall risk on admission and reassessed the day after admission. Patient #3 was not reassessed after the fall on 10/15/10.

Patient #4:
Patient #4 was admitted to Hospital #1 on 7/18/10 at approximately 7:40 P.M. Patient #4 experienced a fall on 7/27/10.

Patient #4 was assessed for fall risk upon admission and was reassessed the day after admission. Patient #4 was not reassessed after the fall on 7/27/10.

Patient #6:
Patient #6 was admitted to Hospital #1 on 11/22/10 at approximately 3:48 P.M. Patient #6 fell on 11/27/10.

Patient #6 was assessed upon admission and reassessed the day after admission but was not assessed after the fall on 9/27/10.

Patient #9:
Patient #9 was admitted to Hospital #1 on 12/3/10 at approximately 1:00 P.M.

Patient #9 was assessed for fall risk upon admission and the day after admission but was not assessed at 4:00 P.M. the day of admission.

Based on documentation review Hospital #1 failed to ensure that fall risk protocol sheet (Addendum B) outlined in the Fall Prevention Policy was completed and included with the care plan for 11 of 11 patients (Patients #1,#2, #3, #4, #5, #6, #7, #8, #9, #10, and #11).

Findings included:

Review of the Policy and Procedure titled Fall/Accident Prevention Policy, revised 8/06, indicated that the patient's care plan will have the identified fall risk (standard or high), the score and the corresponding individual interventions added to their medical record (Addendum B)

Review of Addendum B indicated that it was a standardized fall risk protocol form that listed standard and high risk interventions. Next to each intervention was a box for the assessor to check off indicating which intervention(s) were applicable to that patient. At the bottom left of the form there was a place for the patient identification sticker.

Review of the Policy indicated there was no evidence to indicate that Addendum B was not part of the medical record.

Review of the fall risk care plan, revised 5/10, indicated that it was standardized form with objectives and interventions. The care plan did not include a space for the risk level or score. Although the care plan had several standard interventions as well as spaces to add interventions it did not coincide with the Policy..

Review of the medical records and care plans for Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 indicated that the care plans did not contain the risk level or score and Addendum B was not present in the medical record.