HospitalInspections.org

Based on policy and procedure review, medical record review, and staff interviews the hospital staff failed to identify, document and report a fall according to policy for 1 of 6 fall risk medical records reviewed (Patient #2).

Findings included:

Review of the hospital policy titled "Fall Assessment, Prevention and Management - Adult Inpatients last revised December 15, 2017", revealed, "This policy provides guidance on assessing patients for fall risk and implementing a fall prevention care plan. ...QUALIFIED PERSONNEL Fall risk assessment Morse Fall Scale may be done by Provider, Registered Nurse, ...EQUIPMENT *Bed alarms and/or other fall monitoring devices * Assistive equipment/devices * Yellow armband ...Post Fall Management: 1. A physical assessment, fall risk reassessment and post -fall huddle will be completed following a fall. 2. Provider and support person(s) are notified of the fall. ...6. Documentation will include but not limited to: (a.) status (location and description of patient) at time of discovery of the fall (b.) circumstances surrounding the event (c.) patient assessment (d.) immediate nursing actions (e.) physician and support person(s) notification (f.) fall prevention interventions reviewed DOCUMENTATION - Documentation in the medical record includes but is not limited to: ...(d.) post fall assessment/interventions VII. DEFINITIONS ... Fall - A patient fall is a sudden, unitentional descent with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can). ... ..."

Review of the hospital policy titled "Quality Assessment Report last revised September 2018", revealed " ...It is the responsibility of all team members including medical staff to report incidents in the electronic incident reporting system (e-RL). Incidents include actual events that reach a patient, as well as near-miss events. ...Incidents are to be entered into the electronic reporting system (e-RL) within 24 hours of occurrence or when a team member becomes aware of the event. ...Incident - Any happening that is not consistent with the routine care of a particular patient or an event that is not consistent with the normal operations of the organization. Near Miss - An event or a situation that did not produce patient harm, because of intervening factors, such as patient health or timely intervention. ..."

Closed medical record review revealed Patient #2 was a 76- year old male admitted under an Involuntary Commitment (Court Ordered) to the hospital on 07/24/2020 through 09/01/2020, with a diagnosis of Dementia and a history of behavior disturbance and other co-morbidities. Record review included the documentation on the H&P (History and Physical) completed on 07/25/2020 at 1135, by MD #1 (Psychiatry Physician)" ...-Disposition - IVC psychiatric hospitalization recommended for risk of self-injury, risk of injury to others and severely impaired judgment ....Precautions: - fall ...Gait and Station - No gait abnormalities ...Affect - Inappropriate, labile, Thought Process - Illogical ...Content/Perceptual - risk of agitation, Evidence of: Hallucinations: Audio and Visual ...Insight - Impaired, Judgement - Impaired. Record review revealed Patient #2 had activity orders on 07/24/2020 as up ad lib (able to ambulate on own will without assistive device), on 08/25/2020 as ambulate in hallway w/without assistive device, and on 09/01/2020 ordered as out of bed as often as possible. During a one-week period of 07/24/202 through 08/01/2020, Patient #2 had a Morse Fall Risk Score (an Assessment tool to determine the likelihood of falling) which ranged from 15 (low risk for fall) to 75 (high risk for fall) with the appropriate fall prevention interventions in place. Record review revealed for the Morse Fall Risk of 75 the patient had documentation of "yellow fall wristband in place, assure assistive devices are available as needed, assist with elimination, mobility, and exercise as needed, call bell and patient items within reach, utilize non-skid footwear, bed/chair alarms on at all times unless accompanied by a staff member, increased rounding, bed in low position with brakes locked, safety rounds performed every 15 minutes, reinforced BH (Behavioral Health) fall risk prevention strategies with patient and /or support person". Record review revealed on 07/31/2020 at 2002, RN #1 documented a Morse Fall Risk score of 40 (low/medium risk), with the fall intervention of "Utilize non-skid footwear". Record review revealed on 07/31/2020 at 2230, an "Event" occurred whereby Patient #2 struck CNA #1, the Patient #2 "lost his balance and fell across his bed, with his head hanging over the edge. ..." Further review revealed RN#1 entered the room after the CNA #1 had called out for help. Review revealed RN #1 administered a prn (as needed) medication (which acts on the brain and nerves to produce a calming effect), Ativan 0.5mg given at 2313, documented as effective in calming the Patient #2 after the "Event". Record review revealed on 07/31/2020, there was no physician assessment of the patient, nor the completion of a Quality Assessment Report after "Event". Review of "Psychiatry Provider Progress Notes" completed by MD #1 on 08/01/2020 at 1314, revealed " ...Review of Systems: A complete review of systems of the following systems was conducted (Constitutional, Psychiatric, Neurological, Musculoskeletal, Eyes, Gastrointestinal, Cardiovascular, Respiratory, Skin and Endocrine. All reviewed systems are negative except pertinent positives identified in the HPI. ..." Review of "Psychiatry Provider Progress Notes" completed by MD #1 on 08/02/2020 at 1304, revealed " ...Review of Systems: A complete review of systems of the following systems was conducted (Constitutional, Psychiatric, Neurological, Musculoskeletal, Eyes, Gastrointestinal, Cardiovascular, Respiratory, Skin and Endocrine. All reviewed systems are negative except pertinent positives identified in the HPI. ..." Record review of "Psychiatry Provider Progress Notes" completed by MD #3 on 08/05/2020 at 1339, revealed " ...I spoke with daughter to review treatment plan. She is upset that he had a bruise and no one recorded this. No bruises or injuries present today. ..." Patient #2 was later discharged home on 09/01/2020 at 1130, into the care of his family.

Telephone interview with RN #1 on 09/09/2020 at 1530, revealed RN #1 was the night shift primary nurse for Patient #2 on 07/31/2020 during the Event A. Interview revealed Patient #2 had fall prevention interventions in place on 07/31/2020, with an activity order for up ad lib and a Morse Fall Risk score of 40 (low/medium risk). Interview revealed Patient #2 struck CNA #1 two times in the face, and when the patient attempted a third strike CNA #1 assisted the patient to descend across the bed. Interview with RN #1 revealed Patient #2 did not fall to the floor, nor did the patient appear to have obtained an injury. Interview with RN #1 revealed it was requested that CNA #1 inform the Assistant Nurse Manager (RN #3) on duty at the time of the "Event" of this occurrence. Interview revealed "Event" was not viewed as a fall nor was there observable injury, thereby the staff did not make notification to the family nor notification to a Psychiatric or Medical Provider.

Interview with CNA #2 on 09/09/2020 at 1315, revealed CNA #2 had provided clinical care for Patient #2 on 08/01/2020. CNA #2 recalled Patient #2 on 08/01/2020 had no visible bruises, scratches or marks of any type. CNA #2 revealed the process of new findings of bruising, scratches or marks of any kind on a patient would require the notification to the Registered Nurse.

Interview with RN #2 (Unit Nurse Manager) on 09/09/2020 at 1540, revealed a visual assessment of Patient #2 on Monday 08/03/2020 yielded no observation of marks or bruises of any kind. RN #2 reviewed video observation of hallway views, chart review and staff interviews regarding Event A which did not reveal any visual concern of Patient #2 having had a fall. Interview with RN #2 revealed the "Event" did not require physician notification. Interview with RN #2 revealed no needed assessment by the unit nursing supervisor because RN #1 assessed the patient did not have an actual fall. A follow-up interview on 09/10/2020 at 1200, was conducted by another surveyor with RN #2 and the DON (Director of Nursing). Follow up interview revealed after further review surrounding the "Event", the "Event" should have been documented as a patient fall which would have a Physician assessment of the patient following the fall, and the completed incident report. Interview revealed the wording of the Hospital Policy was nebulous, therefore the DON had stated she intends to bring the policy up before the board for review.

Interview with CNA #1 (involved with the "Event") was unavailable. CNA #1 is out on unrelated leave of absence.

Interview with RN #3 on 09/10/2020 at 0900, revealed RN #3 was on duty 07/31/2020 during the "Event". Interview revealed she had not been notified of a patient fall which would require the completion of an event report. Interview revealed nor had she been notified of the CNA being struck in the face which also would have required a Quality Assessment Report to be completed.

NC00168046