HospitalInspections.org

Based on document review and interview the facility failed to ensure care in a safe setting related to fall risk precautions in 1 (patient 1) of 10 medical records (MR) reviewed:

Findings include:

1. Patient 1's MR: Review of Admission Assessment dated 1/22/20 at 2251 hours per staff N5 (Registered Nurse [RN]) indicated: "...Fall Risk Assessment: Total 96 (High Fall Risk = Score of 90 or greater)...". Review of Care Plan/Falls Treatment Plan dated 1/22/20 lacked documentation high fall risk interventions were initiated on admission (1/22/20).

2. Policy/procedure, Policy Number: RE 16, Psychiatric Patient Rights, revised/reviewed 9/19, indicated:
A. Page 1: "You have the right to: 4. Be treated in a safe environment..."
B. Page 2: "A current individualized treatment plan that addresses your needs. Your individualized treatment plan will be specific and identify appropriate and adequate services...".

3. On 2/25/20 at approximately 1200 hours, staff N7 (Director of Nursing) was interviewed and confirmed patient 1 experienced a fall on 1/26/20 at 0600, 1600 and 2030 hours; 1/30/20 at 0700 hours and 2/1/20 at 0747 hours. Staff N7 confirmed staff failed to initiate high fall risk precautions on admission (1/22/20). Staff N7 confirmed staff failed to follow patient 1's individualized treatment plan by ensuring high risk fall precautions were implemented on admission (1/22/20).

Based on document review and interview the facility failed to ensure nursing staff followed their policies/procedures related to patients assessed to be high risk for falls in 1 (patient 1) of 10 medical records (MR) reviewed:

Findings include:

1. Review of patient 1's MR lacked documentation high fall risk interventions were initiated on admission (1/22/20) and lacked documentation of neurochecks post-fall on 1/26/20 at 1600 hours. Review of patient 1's MR also lacked documentation staff updated the PM Shift Patient Monitoring Round forms on 1/26/20, 1/29/20, 1/30/20, 1/31/20 and 2/1/20 indicating current precaution levels including precaution for high fall risk.

2. Policy/procedure. Policy Number: NU09, Fall Prevention Protocol, revised/reviewed 12/17, indicated: "All patients admitted to Assurance Health will be placed on fall prevention protocol. High Risk Fall Interventions/Identifiers: All low risk interventions plus one or more of the following...".

3. Policy/procedure, Policy Number: NU 3, Assessment Neurological, revised/reviewed 9/2018, indicated: "The Registered Nurses assigned to the patient will provide neurological assessments and reassessments when a neuro deficit is suspected, or the assessments are ordered by a physician or post fall events and the patient has hit his/her head".

4. Policy/procedure, Policy Number: NU 60, Patient Rounding, revised/reviewed 9/18, indicated: "To provide guidelines for insuring a safe and therapeutic environment...All staff assigned will update the round sheets during their shift to reflect any changes in precaution level, room or bed changes".

5. On 2/25/20 at approximately 1200 hours, staff N7 (Director of Nursing) was interviewed and confirmed patient 1 experienced a fall on 1/26/20 at 0600, 1600 and 2030 hours; 1/30/20 at 0700 hours and 2/1/20 at 0747 hours. Staff N7 confirmed staff failed to initiate high fall risk precautions on admission (1/22/20). Staff N7 confirmed patient 1's MR lacked documentation of neurological checks post-fall on 1/26/20 at 1600 hours as directed per medical staff D3. Staff N7 confirmed staff did not follow the facility's policy/procedure for patient rounding by failing to document patient 1's precaution levels, including high risk for falls.