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4605 MACCORKLE AVENUE SW

SOUTH CHARLESTON, WV 25309

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on document review, medical record review and staff interview, the hospital failed to ensure the nursing staff follows hospital policy in five (5) of ten (10) medical records (Patient #1, 6, 7, 9, 10) reviewed. This has the potential to negatively impact all inpatient care by not reducing the risk of patient falls. Findings include:

1. Thomas Memorial Hospital (TMH) policy Falls/Entrapment Prevention Plan, last revised 2/10, states in part "... Level III Setting: Patient settings identified as having the highest risk for falls. These settings include: All inpatient areas...III. D. It is the responsibility of the primary RN (Registered Nurse) or LPN (Licensed Practical Nurse) admitting the patient to screen for potential falls and entrapment if applicable, and, as necessary, implement prevention measures. It is also the responsibility of the primary RN or LPN to educate the patient/significant other of basic safety measures to ensure a safe environment and document interventions and education provided. IV. Falls Prevention Policy: Level III Setting (Inpatient Areas): Patients admitted to Level III settings at TMH are screened, at the time of admission, for risk of falls. Those patients assessed to be at risk for falls are placed under increased surveillance until reassessment no longer indicates the need. A. Assessment 1. Identify the patient in need of Falls Prevention Program through the "Safety Risk Assessment"...2. Patients are reassessed each shift for safety risks...
3. Patients are reassessed and re-scored after a fall... B. Plan/Implement 1. Fall prevention is documented on the plan of care based on the results of the Safety Risk Assessment...2. Document interventions per risk scale parameters (Low Risk/High Risk). *If intervention is contraindicated based upon assessed need, document rationale in the nurses' notes... 3. General Safety measures are to be initiated on all patients... 4. Low Risk (Score 0-4): General Safety Measures are in place... 5. High Risk (Score 5-30): the following are initiated and documented: General Safety Measures; Initiate the "Falling Stars" identification system...a) Place fall precautions sticker on front of patient's chart; b) Place "Fall Precautions" sign at patient's door "Blue Star" = Patient at risk for falling, "Red Star" = Patient has fallen and patient is at greater risk; c) If possible, move the patient closer to the Nurses' Station; d) Answer call light promptly; e) Make rounds every two (2) hours or more frequently as indicated, assessing personal needs...Consider bed alert device (as indicated)..."

2. Review of the medical record for Patient #1 revealed the patient was initially admitted to the hospital's Psychiatric Unit on 7/30/10 and then transferred to the Med/Surg Unit on 8/7/10. Review of the Internal Transfer and Handoff Communication Form revealed documentation by the transferring nurse of the patient being confused and having an unsteady gait. Further review revealed documented evidence of the patient falling on 8/4/10, while still on the Psychiatric Unit, receiving a skin tear injury to the top of the left hand. Documented evidence by the receiving nurse revealed the patient was alert only to place and answered questions appropriately at intervals. A nurse's note dated 8/8/10 at 1113 revealed documented evidence of the patient being escorted back to assigned room after being found wandering in the hallway toward the exit elevators, being worried about great grandson, thinking he is lost and in danger. Further review of the medical record revealed a nurse's note dated 8/9/10 at 1029 documenting the patient getting out of a chair and wandering into the public restroom where the nursing staff located the patient locked-in. After getting the door unlocked, the patient was found sitting in the middle of the floor with a gash over the left eye and blood on the toilet and a wet paper towel. Documented evidence revealed no bed or chair alarm had been in use prior to the fall.

3. Review of the medical record for Patient #6 revealed the patient was an 86-year old admitted with a Left Rotator Cuff Tear and to be a Fall Risk of 13-17 (High) during admission. However, documentation of the use of the bed alarm was inconsistent with no documentation supporting why the alarm was not in-use.

4. Review of the medical record for Patient #7 revealed the patient was a 72-year old admitted with a Right Hip Fracture due to a fall and to be a Fall Risk of 7-12 (High) during admission. However, documentation of the use of the bed alarm was inconsistent with no documentation supporting why the alarm was not in-use.

5. Review of the medical record for Patient #9 revealed the patient was a 90-year old admitted with Back Pain due to a fall and to be a Fall Risk of 9-13 (High) during admission. However, documentation of the use of the bed alarm was inconsistent with no documentation supporting why the alarm was not in-use.

6. Review of the medical record for Patient #10 revealed the patient was a 49-year old admitted with a Non-healing Diabetic Ulcer of the Right Foot and to be a Fall Risk of 2 (Low). Further review of the patient's medical record revealed the patient to also be a left above the knee amputee (LAKA). Documented evidence revealed the patient fell during the night of 8/11/10. There was no documented evidence of alarms being used after the patient's fall.

7. During an interview with the Unit Manger (UM) in the afternoon of 8/12/10, the medical records were reviewed and the UM agreed with the above findings.