HospitalInspections.org

Based on document review and interview, the facility failed to ensure a registered nurse supervised and followed established policy/procedures for Fall Prevention and Management System for 2 of 5 medical records (MR) reviewed (Patient #1 and 2).

Findings include:

1. Review of policy/procedure, Fall Prevention and Management System, indicated the following;
" J. If the patient has a fall or near fall, the patient is to be examined to determine if an injury has occurred, and the level of injury:
- Notify the physician and family if a fall has occurred. "
This policy/procedure was last reviewed / revised on 02/12.

2. Review of patient #1 ' s MR indicated the following on 05-01-12 at 0131 hours; " This staff RN was asked by CNA to help assist patient to BSC (bedside commode). Upon entering room, pt, was found sitting in floor at bedside with her walker in front of her. Pt stated that she slid off her bed onto floor. " The patient ' s MR lacked documentation that the family was notified of the fall.

3. Review of patient #2 ' s MR indicated the patient fell from bed on 05-05-12 at 1840 hours and the patient ' s MR lacked documentation that the patient ' s family was notified of the fall.

4. On 05-24-12 at 1215 hours, staff #42 confirmed that patient #1 ' s family was not notified of the fall by the RN assigned to care for the patient on 05-01-12 at 0131 hours.