HospitalInspections.org

Based on policy review, medical record review, and staff interviews, nursing staff failed to supervise patient care by failing to prevent a fall resulting in an injury for 1 of 3 unwitnessed falls reviewed (Patient #7).

The findings include:

Review of a policy titled "Falls Risk Assessment and Prevention," with revision date of 12/07/2017 revealed "Purpose: The goal of the fall prevention plan is to establish guidelines and methods to assess/screen inpatients at risk for falling within the organization....Definitions: A. Fall--A fall is defined as any sudden, unintentional change in position that causes an individual to land at a lower level, on an object, on the floor, or on the ground....Witnessed or Unwitnessed Fall--A fall can be witnessed or unwitnessed. If a patient is found on the floor it is assumed the patient had an unwitnessed fall.....Predicting and Preventing Falls: A successful falls prevention program requires a systematic method for identifying patients who are at a higher risk for falling, so that fall prevention resources can be targeted where they are most needed. Screenings: Inpatients will be screened utilizing the Morse Falls Scale Risk Screen.....Screens are completed on admission, every shift, and as indicated with changes in condition.....The Morse Fall Scale is the assessment tool used for assessing risk factors. The scale assigns points to specific risk factors. The level of risk and subsequent fall precaution measures such as "low risk," "medium risk," or high risk" precautions are then initiated based on the range in which the patient scores....3. Patients who score 51 or above are considered to be "High Risk" for falls.....Morse Fall---Greater than or = 51. Risk Fall Interentions include: All of the low/moderate interventions apply---with the following additions: 1. Staff remain within visual, auditory, or at arms length during toileting. 2. Bed alarms. 3. Chair alarms as needed....."

Review of a policy titled "Sitter Usage" with revision date of 08/23/2018 revealed "Purpose: This policy outlines the guidelines for protecting patients from causing harm to themselves....Patients may include those with organic causes......Assessment of Sitter Usage: The nurse assesses for and considers the following criteria/risk factors for sitter usage: ....5. Cannot follow safety instructions (getting out of bed without notifying staff, high risk for falls, etc.)..."

Review of a History and Physical for Patient #7 dated 03/04/2019 at 0347 revealed "The patient is a 94 year old nursing home resident with a history of hypertension, diabetes and dementia who presents with episodes of bright red blood per rectum....her caretakers noted that she was having several episodes of bleeding....with diagnosis of GI bleed (Gastrointestional bleed)." Review of a Falls Risk Nursing assessment dated 03/04/2019 at 1245 revealed "High Risk/Over 51/High Risk Fall Prevention .... Pt on anticoagulants automatic high risk .... " Review of a Shift summary nursing note dated 03/08/2019 at 0750 revealed "Unable to assess patient at current time. Pt is very agitated. Pt sitting on side of bed. Unable to get patient to lay back in the bed due to patient stating, 'don't touch me, don't come in here, get out of my face.' Family notified and asked to come visit patient. Family said they were on their way. Bed alarms unable to be set to most sensitive. Bed alarms currently set to most sensitive available for patient's current postion."

Review of RN #1's nursing assessment for Patient #7 dated 03/08/2019 at 0830 with amendments at 0850 revealed "Pt (Patient) landed on floor, unwitnessed, Pt assisted to bed by Security and CNA. Physician notified, X-ray ordered, assessment unchanged....What was Pt trying to do at time of fall: To reach personal items. Where was the Pt at the time of the fall: Room."

Review of CT scan (an x-ray image using x-rays and computers to create pictures of organs, bones, and other tissues) dated 03/08/2019 at 0935 revealed "History: Fall, pain....Impression: 1. Minimally displaced comminuted greater trochanteric fracture..."

Interview on 05/02/2019 at 0845 with a nursing supervisor (RN #2) revealed she worked on the day of the patient's fall on March 8, 2019. Interview revealed there was a change in the patient's behavior from the previous day and the assigned nurse had called the family. "I suggested an RN to park outside of the patient's room for safety." Interview revealed there was not a nurse sitting outside of the door when the fall occurred. Interview revealed a sitter should have been assigned with the patient while waiting for the family.


NC00149614