HospitalInspections.org

Based on observation, record review and interview, the RN failed to supervise and evaluate the nursing care for 1 (#1) of 2 patients (#1, #2) who had a fall event as evidenced by failing to assess the patient for injuries after a reported fall, failing to document the event in the nurse notes and failing to notify the family of the event.
Findings:

Review of the hospital's policy for Fall Assessment/Reassessment and Precautions, revised 11/16/2022, revealed in part, the following: "Fall" refers to unintentionally coming to rest on the ground, floor, or other lower level.

Further review of the policy for inpatients revealed the following:
#2 - In the event of a fall occurrence, patients will be re-assessed and additional fall prevention interventions will be implemented.

Review of the Procedure, in part, revealed the following:
#6 - Post fall interventions shall include:
RN physical assessment of the patient;
Obtain vital signs including pain assessment;
Initiate neurological assessment if fall was unwitnessed or if fall resulted in head injury;
Notify Physician/Non-physician practitioner (NPP) and ER orders as needed;
Conduct a re-assessment of fall risk using the fall risk tool;
Implement secondary fall prevention interventions from the additional precautions interventions list and update Fall Risk related Treatment Plan with individualized interventions; Complete Post-Fall Checklist.
#8 - An incident report will be completed in its entirety and forwarded to the DON after every fall.
Further review of the policy and procedure for post-fall events revealed no evidence of a requirement to notify the family or responsible party.

Review of the Psychiatric Evaluation and H&P reports for Patient #1 revealed a 55 year old male admitted 08/14/2024 with diagnoses including dementia with behaviors, major depressive disorder, and generalized anxiety disorder. He exhibited paranoid delusions, and was followed by a neurologist for jerking movements. He had trouble gathering his thoughts and getting them out. He was able to answer questions appropriately, but was very confused.

Review of the Nursing Assessment for Patient #1 dated 8/14/2024 at 12:15pm revealed the skin assessment was normal with skin intact. Fall precautions were put in place (armband, non-skid footwear, bathroom light). He required assistance with some ADLs. Other precautions included suicide/self harm and violence. He was placed on every 15 minute observation level.

Review of video footage dated 08/16/2024 at 7:38am with S1ADM revealed Patient #1 was outside on the patio area with a group of patients and two staff members in attendance. As he stepped onto the concrete patio from the grass, Patient #1 stumbled and fell forward, landing on the picnic table. His chest and upper arms took the brunt of the fall, hitting hard on the edge of the table top, with his knees landing on the bench seats, and his face landing on the top surface of the table. Patient #1 immediately got up, refusing the staff's assistance and began walking around. Further observation of Patient #1 on the video footage revealed no obvious visible evidence of bleeding or other injuries. At 7:42am, Patient #1 walked inside the building unassisted. Interview at this time with S1ADM revealed he was not aware of the fall event until the family visit at the time of discharge when Patient #1 reported it to the family.

Review of the medical record for Patient #1 revealed no documented evidence of a fall event during his stay from 08/14/2024-08/16/2024. On 08/27/2024 at 1:00pm, an interview with S3RN confirmed that the MHT that was outside when the incident occured reported the event to her a "little while" later. S3RN stated she was on rounds with the nurse practitioner at the time of the incident, and found out about it later. She confirmed that she did not complete an incident report or assess the patient because it seemed like an insignificant event at the time, as it was reported to her that the patient had stumbled and caught himself on the table. S3RN stated that she did not consider it to be a fall. She further stated she had seen the patient several times during the day and she did not notice any injuries, nor did he complain of any pain. She further confirmed that she did not notify the practitioner, supervisor or family of the event.

On 08/27/2024 at 2:00pm, an interview with S2DON confirmed that family notification is required as part of the post-fall procedures, and should be included in the policy and procedure. She further confirmed that the requirement was not documented in the policy.

Review of the medical record revealed Patient #1 was discharged AMA with the family on 08/16/2024 at 4:30pm. Review of the medical record from Hospital A revaled he was seen in the ER on 08/16/2024 at 4:51pm, and was noted to have a contusion of the rib on the right side.