HospitalInspections.org

Based on record review and interview the facility failed to ensure that registered nurses supervise and evaluate the nursing care for patients after an adverse event in two of seven (Patient ID #1, 6) patients who had fallen and hit their head.

Findings Included:

Record review of the facility policy "Fall/Safety Assessment" reviewed 9/20 stated for Fall Prevention Precautions:

High Risk >45: Implement Moderate risk interventions in addition to Bed Alarm/Chair alarm in place and on.

E. Post Fall Procedure Assessment and Documentation:
e. Head injury or unknow if hit head, following the fall requires
i. V/S & Neuro checks every 15 minutes x 1 hour
ii. Then every 30 minutes x 2 hours
iii. Then every 1-hour x 2 hours, then as previous ordered.

Record review of the incident reports for August and September 2020 reviewed six (6) incidences for August and one (1) for September. Two out seven (patient ID #1, 6) patient were noted to have fallen and hit their head.

Record review on 10/01/2020 at 1300 of patient's (ID#1) incident record dated 08/12/20 at 1910 revealed she was found on the floor from an apparent fall. Further investigation of her medical record revealed she was found by a registered nurse (staff ID# 53), who did not take vital signs or neuro checks per hospital policy.

Record review on 10/01/2020 at 1310 of patient's (ID#6) incident report dated 08/07/20 at 1000, revealed the dietary staff (ID#60) saw the patient (ID #6) fall and hit his head on the floor. Further investigation of the incident report and the medical record documented by a registered nurse (staff ID#54) revealed no vital signs or neuro checks were completed per hospital policy.

Interview on 10/1/2020 at 1335 with Quality Manager (ID#51) during chart review of both patients (ID#1, 6) confirmed there we no vital signs taken. She stated, "yes, madam, especially with a head injury and the doctor asking for a CT scan (computerized tomography), no vital signs and neuro vital signs were done".

Other findings included:

Observation on 10/01/20 at 1430 with the Quality Manager (ID#51) during rounding on the medical surgical unit revealed three patients were noted to be high risk for fall precautions with notices on their door. Two patients (ID#9, 11) out of the three patients identified as high risk did not have their bed alarm on.

Interview on 10/01/20 during the time of observation with the (ID#51) Quality Manager who stated, "they should have the bed alarm on."