HospitalInspections.org

Based on medical record review, document review and interview, the facility failed to analyze incidents for patient falls. In particular, the facility did not analyze the cause of the events and did not identify areas for improvement and implementation of corrective actions.
This was identified in nine (9) of 16 medical records reviewed.

Findings:

Review of medical record for patient # 1 identified this 91-year-old female patient who came into the facility's Emergency Department on 03/05/2023, at 08:42 am, complaining of weakness and intermittent chest pain to her right side.
On 03/05/2023, at 04:07 pm, patient was admitted to room 4422-1 of 4 South Telemetry unit for observation and further evaluation. The Morse Fall Risk (Fall Risk Assessment tool that predicts the likelihood that a patient will fall) was documented as high and mental status as "overestimates/forgets limitations." Patient had a history of falls.

On 03/08/2023 at 10:32 pm, patient was transferred to room 5222-1 of 5 North Medical - Surgical Unit.
On 03/09/2023, at 12:15 am, a nurse documented, "Pt observed walking toward door of her room when she fell. This nurse was able to slow her fall by catching her and lowering her to the floor .... Pt had disabled personal alarm by turning off switch on alarm unit."

The post fall documentation dated 03/09/2023, at 12:15 am, stated the patient sustained a hip injury requiring surgical intervention.

During interview on 05/30/2023, at 02:56 pm, Staff A, Registered Nurse, recalled that the "patient acted erratically. She had a personal alarm, but the switch was off. I personally put in a battery. There is also one on the bed, but I do not recall it was going off."


Review of the "Performance Improvement Ancillary/Nursing Department Review," Review Date: 03/16/2023, revealed a timeline of the patient's clinical progression during the hospital stay. In the section "Brief Summary Investigation" it is entered, "RN documents PA" (Personal alarm) and bed alarm in place."
In "Review of Findings" section, it is documented that a pertinent policy and procedure was not followed, and that the unit staff was educated/counseled.

During tours of 5 North Unit on 05/26, 05/30, and 06/02/2023, nurses were asked if they received any training on falls post incident with patient #1. Nurses were unable to recall the incident.
Staff G, H, K, R, S, and T, Registered Nurses, stated that they receive their training on falls during huddles each shift, which includes, but is not limited to discussion of each patient's condition in general, and those who are at risk for falls in particular.
The nurses also stated that fall risk precautions measures such as placement of a bed and/or a personal alarm are based on nursing judgement.

During interview on 05/30/2023, at approximately 03:30 pm, Staff C, Nursing Quality Improvement Coordinator, stated that she was unsure which policy was not followed, since the training to the unit staff was performed by the Unit Director of 5 North, who is currently on vacation. She was also unable to provide evidence of education for the unit staff for the same reason.

On 05/30/2023, at 01:25 pm, during an interview with Staff M, Administrator for Nursing Professional Development, she stated that she was unaware of the patient's fall and did not provide training on fall precautions to staff. She also confirmed that fall precautions measures are subject to nursing judgement.


Review of the policy titled "Falls: Reduction and Prevention," updated on 05/17/2021, revealed that "Safety huddles will be conducted four times daily to identify patients at risk for falls as well as strategies implemented to reduce the potential of a fall/fall with injury."

Review of the policy titled "Quality and Safety Adverse Event - Occurrence, Never Event, & HAC (Hospital Acquired Conditions) Process: Reporting, Follow - up, & Billing," Revised: 02/2021, revealed:
"Event/Occurrence Follow - Up
1. Each event/occurrence is automatically transferred to a work list in the MIDAS RDE system. (The facility's electronic system)
2. Each Day, Directors review their work list in the MIDAS RDE system.
3. Events/occurrences in the work list are reviewed and investigation launched.
4. Directors identify cause(s) of each occurrence and implement actions to ensure such events do not occur again...."


On 06/02/2023, at approximately 04:30 pm, these findings were brought to the attention of facility's administrative personnel during exit conference.


Similar findings were identified for patients #2, #3, #4, #5, #6, #7 and patient #15 #16. Example:
a) A single page document, not titled, documented patient #4, fall with injury 1/19/23.
A summary of what occurred was documented. There was no documented evidence of a thorough investigation, no documented corrective actions.

Similar findings identified for patient # 5, fall with injury 1/4/2023
-patient #6, fall with injury 2/3/2023
-patient #7 fall with injury 4/19/2023
-patient #16 fall 1/13/2023.

b) The "Performance Improvement Ancillary/Nursing Department Review" for patient #2, documented fall 3/6/2023. There was no documented evidence of a thorough investigation, no documented evidence of education provided.
Similar findings were identified for patient #3 documented fall with injury 03/07/2023 and patient #15 documented fall with injury 4/12/2023.


There is no evidence the Directors identified the cause(s) of each occurrence and or implemented actions to ensure such events do not occur again.

Based on medical record review, document review and interview, the facility failed to:

a) Ensure that a nursing care plan and safety strategies were maintained for a patient identified as high risk for falls patients. (Patient #1)

b) Conduct thorough investigations for patients' fall incidents and implement corrective actions. (Patients #1 through #7 and #15, #16).

As a result, Patient #1 sustained a fall with injury and required surgical intervention.


Findings:
a) Review of medical record for patient # 1 identified this 91-year-old female patient who came into the facility's Emergency Department on 03/05/2023, at 08:42 am, complaining of weakness and intermittent chest pain to her right side.

On 03/05/2023, at 04:07 pm, patient was admitted to room 4422-1 of 4 South Telemetry unit for observation and further evaluation. The Morse Fall Risk was documented as high and mental status as "overestimates/forgets limitations." Patient had a history of falls.
There is documentation of the use of personal alarm, bed alarm, monitoring and rounding for patient safety.

On 03/08/2023 at 10:32 pm, patient was transferred to room 5222-1 of 5 North Medical - Surgical Unit.

On 03/09/2023, at 12:15 am, a nurse documented, "Pt observed walking toward door of her room when she fell. This nurse was able to slow her fall by catching her and lowering her to the floor .... Pt had disabled personal alarm by turning off switch on alarm unit."



b) Review of "Performance Improvement Ancillary/Nursing Department Review," Review Date: 03/16/2023, for patient #1 revealed that the facility failed provide evidence that the occurrence was thoroughly investigated, and corrective measures are implemented.

Similar findings were identified for patients #2, patient #3, patient #4, patient #5, patient #6, patient #7, patient #15 and patient #16.



See Tags: A 286 and Tag A 396.

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Based on medical record review, document review, and interview, the facility failed to maintain nursing care plan and safety strategies for a patient identified as high risk for falls.

Findings:

Review of medical record for patient # 1 identified this 91-year-old female patient who came into the facility's Emergency Department on 03/05/2023, at 08:42 am, complaining of weakness and intermittent chest pain to her right side.

On 03/05/2023, at 04:07 pm, patient was admitted to room 4422-1 of 4 South Telemetry unit for observation and further evaluation. The Morse Fall Risk (A Fall Risk Assessment tool that predicts the likelihood that a patient will fall) was documented as high and mental status as "overestimates/forgets limitations." Patient had a history of falls.

At 11:04 pm, a nurse documented in the medical record, "Patient in bed multiple attempts to get out of bed, patient re-oriented on nurse call light use, PA" (Personal Alarm) "on patient, bed alarm on patient, patient bed at nursing station, routine rounding going on safety."

On 03/08/2023, at 03:48 am, a nurse documented in the medical record, "Pt repeatedly attempting to get OOB unassisted. Pt removed telemetry and was attempting to remove IV ....
Pt medicated as ordered. PA remains in place, safety precautions maintained."

At 05:50pm, a nurse entry in the medical record, "Pt still attempting to get up .... Frequent rounding in place. PA in place."

On 03/08/2023 at 10:32 pm, patient was transferred to room 5222-1 of 5 North Medical - Surgical Unit.

On 03/09/2023, at 12:15 am, a nurse documented in the medical record, "Pt observed walking toward door of her room when she fell. This nurse was able to slow her fall by catching her and lowering her to the floor .... Pt had disabled personal alarm by turning off switch on alarm unit."

Post fall documentation dated 03/09/2023 at 12:15 am, noted the patient sustained a hip injury requiring surgical intervention.

On 03/09/23, a nurse made an entry in patient's medical record at 8:00pm, based on the risk assessment checklist; the patient's risk for falls was high, Morse Risk Assessment Score was entered as high as well. Patient's mental status was entered as "overestimates/forgets limitations." In the checklist entry, it is noted that this patient needed "chair/bed alarms."

There was no documented evidence in the medical record that fall precaution measures were maintained for patient #1 when patient was transferred to the 5 North Unit.

On 05/26, 05/30, and 06/02/2023 during the tours of 5 North Unit nurses were interviewed. During the interviews, Staff G, H, K, R, S, and T, Registered Nurses, stated that use of bed and personal alarms is subject to nursing judgement.
Nurses were asked if they received any training on falls post incident with patient #1. Nurses were unable to recall the occurrence. The nurses stated that they receive their training on falls during huddles each shift which includes, but not limited to discussion of each patient's condition in general, and those who are at risk for falls in particular.

On 05/30/23, at 01:25 pm, during an interview with Staff M, Administrator for Nursing Professional Development, she confirmed that fall precautions measures are subject to nursing judgement.

During interview on 05/30/2023, at 02:56 pm, with Staff A, Registered Nurse, he recalled that the patient "acted erratically. She had a personal alarm, but the switch was off. I personally put in a battery. There is also one on the bed, but I do not recall it was going off"

Review of the policy titled "Falls: Reduction and Prevention" (Updated on 05/17/2021) revealed that "All patients are screened and assessed for fall risk using the Morse Fall Risk Scale....Morse Fall Risk assessments are documented in the Daily Care flowsheet of the Electronic Health Record (EHR). The RN selects 'Fall Tips' patient specific interventions based on Morse fall risk indicators....

On 06/02/2023, at approximately 04:30 pm, these findings were brought to the attention of facility's administrative personnel during exit conference.