HospitalInspections.org

Based on medical record review, interview and review of facility policy, the hospital failed to ensure patients were supervised and evaluated by nursing staff (A395).

Based on record review and interview, the hospital failed to ensure nursing staff completed post fall assessments and huddle forms after patient falls; failed to document the incidents in the nursing notes per facility policy for five of 14 medical records reviewed for patients with falls (Patients #4, #9, #3, #2, #5); and failed to ensure nursing staff implemented interventions as ordered for two of 14 medical records reviewed for patients with falls (Patient #4 and #9). The sample size was 14 patients. The facility census was 54.

Findings include:

Review of the policy and procedure titled "Falls Prevention and Monitoring, Policy" Stat ID: 4132379, origination: 10/20/17, last approved 10/20/17, revealed policy area: Provision of Care included that a patient fall is an unplanned descent to the floor with or without injury to the patient. A fall is when a patient lands on a surface where you wouldn't expect to find a patient. All unassisted and assisted falls are to be included whether they result from physiological reasons (fainting) or environmental reasons (slippery floor). Review of page two of four revealed a falls risk re-assessment is completed when there is a change in condition and after a fall. Following a fall, nursing will complete a post fall "Morse Fall Scale" assessment and a "Medications Falls Risk Score" tool identifying when specific areas could have potentially caused the patient to fall; a post fall huddle form will be completed and document in the medical record the incident, outcome, and initial and ongoing observations and interventions put in place as needed to prevent a future fall from reoccurring.

Review of the policy and procedure titled "Assessment/Reassessment Policy" Stat ID: 4830110, created: revised: 04/18, revealed policy area: Provision of Care included reassessments are conducted by all disciplines as indicated. Documentation is provided through a variety of formats including but not limited to progress notes, nursing reassessment forms, medical staff dictation, and by the Registered Nurse (RN) in shift note. In addition, each patient is reassessed as necessary based on the patient's plan for care or change in their condition, including change in the patient's level of pain.

1. Review of the medical record for Patient #4 revealed the patient was admitted to the facility on 07/03/18. The admitting diagnoses included major depression with psychosis, dementia and behavioral disturbance Parkinson's type.

Review of the admission nursing assessment dated 07/03/18 revealed Patient #4 was a high fall risk. The nursing assessment identified Patient #4 could be out of bed ad lib, stand by for safety as needed and for dressing, and for bathing and toileting the patient needed supervision. The treatment plan included 15 minute checks since admission. The medical record also revealed a physician order dated 07/10/18 for a chair alarm when up in the chair and a bed alarm when in bed.

Review of the observation log for 15 minute checks revealed on 07/16/18 at 4:00 PM and 4:15 PM the patient was in his/her room, asleep, lying/sitting and quiet. The observation log was also check marked as not applicable for a bed or chair alarm. Instead "other" was check marked and the word "walker" was written in.

Review of the incident log revealed Patient #4 had a fall on 07/16/18 at 4:20 PM. Patient #4 was found on the floor next to his/her bed on his/her right side. Patient #4 stated he/she was going to the bathroom and lost his/her footing and fell. There was no documentation in the nurses' notes in regard to the patient's fall for 07/16/18 from 7:00 AM to 7:00 PM or from 7:00 PM to 7:00 AM the next day.

The medical record lacked documented evidence of a post fall assessment or post fall huddle form completed after Patient #4's fall that happened on 07/16/18.

Review of the 15 minute check observation form dated 07/17/18 revealed at 3:30 AM, Patient #4 was in his/her room after he/she returned from the hospital. The observation form had a bed and chair alarm marked as safety devices. Further review of the 15 minute check observation forms dated 07/18/18, 07/31/18 and 08/01/18 did not have the bed alarm or the chair alarm marked as in place.

Further review of the incident log revealed Patient #4 had a fall on 07/31/18 at 10:15 PM. Patient #4 was found by Patient #10 on the floor lying on his/her back in Patient #10's bathroom. There was no documented evidence a post huddle form was completed.

Interview with Staff A on 09/18/18 at 2:00 PM confirmed there was no nursing documentation for the patient's fall on 07/16/18, and no post fall assessment or post huddle form completed. Staff A also confirmed there was no post huddle form completed for the fall that happened on 07/31/18.

Interview with Staff A on 09/20/18 at 9:40 AM confirmed the 15 minutes check observation forms dated 07/18/18, 07/31/18 and 08/01/18 should have been marked for the bed and chair alarm since there was no order to discontinue.


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2. The medical record review for Patient #9 was completed on 09/19/18. The medical record review revealed the patient was admitted to the facility on 09/07/18 at 1:47 AM. The medical record review revealed a psychiatric note dated 09/07/18 at 10:18 PM that stated the patient was found at home in his/her yard, confused and being licked by dogs. The note stated he/she took excessive amounts of lithium when depressed. The note described the patient as hypertalkative with poor impulse control.

On 09/07/18 at 1:15 AM, the patient was assessed as having a low fall risk.

Review of an incident report dated 09/07/18 at 5:15 PM revealed the patient fell in his/her room during ambulation. Review of the nursing notes dated 09/07/18 did not reveal a description of the fall.

The medical record review revealed a nursing care plan dated 09/07/18 that documented the patient was a high fall risk and was provided with a wheelchair and an "alarm." The care plan did not specify what type of alarm was to be provided.

The medical record review revealed a nursing note dated 09/11/18 at 11:30 AM that stated the patient fell out of the wheelchair to the ground, lying on his/her face, unresponsive for one to two minutes, and became responsive after sternal rub.

Review of the 15 minute check observation form did not show a chair alarm, bed alarm, or floor mat alarm was in place throughout the day.

The medical record review revealed a physician's order dated 09/11/18 for an alarm for when patient was in bed and chair.

The medical record review revealed patient observation notes on 09/12/18, 09/13/18, 09/14/18, and 09/16/18 that showed this was not done.

The medical record review revealed a nursing note dated 09/17/18 that stated, "Patient fell out of wheelchair at 3:45 AM 09/17/18. Physician called." The note did not provide further details.

Review of an incident report dated 09/17/18 revealed the patient fell at 3:45 AM. The report revealed that staff had heard the patient's bed alarm and staff went to check on the patient. The patient wanted to get up and the patient was placed in a wheelchair and brought to the group room to watch television. The note went on to say that a loud sound was coming from the patient's room and when staff went to check the patient, they found him/her on the floor lying on his/her right side.

Review of the patient observation sheet of 09/17/18 revealed the patient had a chair alarm and bed alarm in place, but that the patient had been sleeping the whole night, from midnight to 7:00 AM.

The medical record review did not reveal where any post fall huddle forms had been completed, and the falls risk score was completed only after the fall of 09/17/18 (and updated to high fall risk). The patient's care plan was updated to include in addition to the bed and chair alarms, to have the patient in line of sight.

On 09/19/18 at 11:30 AM in an interview, Staff A confirmed the falls did occur, that no post fall huddle forms were completed, that the patient observations forms stated bed and chair alarms were not in place, and the only fall where a post fall risk score was computed was after the fall of 09/17/18.

3. The medical record review for Patient #3 was completed on 09/19/18. The medical record review revealed the patient was admitted on 08/21/18 and a psychiatric evaluation on that date stated the patient was admitted for agitation and aggression. The note stated he/she was hospitalized for anxiety, combativeness with staff, kicking and throwing items.

The medical record review revealed an admission falls risk score, dated 08/21/18 at 7:30 PM, that stated the patient was a high fall risk, noting the patient had a history of falls.

The medical record review revealed a nursing note dated 08/26/18 at 4:35 AM that stated at 11:05 PM the patient had fallen and a skin tear was noted to the left hand.

The medical record review revealed a psychiatric progress note dated 08/27/18 that stated the patient had fallen and had a "significant" laceration and bruising on her left hand. The note stated she also fractured a toe.

There was no documentation in the medical record on the circumstances surrounding the fall.

On 09/18/18 at 10:30 AM in an interview, Staff A stated the patient had been found at the threshold of his/her own bedroom, confused, crying, and stating that he/she was trying to go to the kitchen.

The medical record review revealed a psychiatric note dated 08/28/18 at 7:16 AM that stated that the patient had yet another fall last night and was again sent out to the hospital. This time the patient was reaching down to the floor to pick something up that he/she had dropped and apparently stooped or slouched over in his/her chair and hit his/her head. The patient was sent out and all test results were negative.

On 09/18/18 at 10:30 AM in an interview, Staff A stated after that fall, the patient was placed on one to one observation.

The review did not reveal where a post fall risk score or post fall huddle form was completed.

On 09/18/18 at 3:16 PM in an interview, Staff A stated neither were completed.

4. The medical record review for Patient #2 was completed on 09/19/18. The medical record review revealed the patient was admitted to the facility on 07/21/18. The medical record review revealed a psychiatric evaluation dated 07/22/18 that stated the patient was hospitalized because he/she wanted to kill himself/herself. The evaluation said the patient lost his/her job, broke up with his/her significant other, and was irritable, anxious and agitated.

The medical record review revealed a nursing assessment with a falls risk assessment dated 07/21/18 that stated the patient was a moderate risk for falls.

The medical record review revealed a nursing note dated 07/24/18 at 5:30 AM that stated the patient was found on the floor in his/her room, lying on his/her back. The note stated the patient stated he/she slipped and fell on the floor while walking to the restroom and was unable to get up. The note said the patient complained of pain in the left hip, ankle and neck.

The medical record review revealed a psychiatric progress note dated 07/24/18 at 10:30 AM that stated the patient had an unwitnessed fall after twisting his/her left leg. The note said he/she was sent to the emergency room and was diagnosed with a sprain.

The medical record review did not reveal where a post fall risk or post fall huddle was done, but did show that a falls care plan was put in place that included educating the patient to use the call light system..

On 09/18/18 at 3:16 PM in an interview, Staff A said he/she did not have documentation of a post fall huddle or post fall risk assessment.

5. The medical record review for Patient #5 was completed on 09/19/18. The medical record review revealed the patient was admitted to the facility on 08/31/18. Review of a psychiatric note dated 08/31/18 at 8:00 AM stated the patient was admitted for being aggressive, combative, delusional and grandiose. The note said he/she had a long history of schizophrenia.

The medical record review revealed a falls risk assessment was performed on 08/31/18. The risk assessment showed the patient was a high fall risk.

The medical record review revealed a nursing note dated 09/04/18 at 5:30 AM that stated the patient had a "fall event" that shift. The note did not describe the circumstances of the event.

The medical record review revealed a physician's progress note dated 09/05/18 at 11:15 AM that stated the patient fell last night, but did not include the circumstances surrounding the fall.

The medical record review revealed the patient was sent to a local emergency department. Review of the emergency department medical record that was included in the patient's medical record revealed a physician progress note dated 09/05/18 at 4:31 PM. The progress note revealed the patient went down to adjust his/her shoe which caused him/her to fall forward. The note said he/she attempted to catch himself with an outstretched left hand.

The emergency department record concluded the patient had a closed radius fracture.

Further review of the patient's medical record did not reveal where a post fall huddle form or post fall risk assessment was done.

On 09/18/18 at 2:00 PM in an interview, Staff A said he/she did not have a completed huddle form or a post falls risk assessment. He/She explained the facility's leadership examined any incident reports (including falls) each morning for the day before. He/She said facility leadership had not been looking to see whether post fall huddle forms had been completed.

Based on record review and staff interview, the hospital failed to ensure all nursing notes were included in the patient's medical record for one of 14 medical records reviewed (Patient #4). The facility census was 54.

Findings include:

Review of the incident log revealed Patient #4 had a fall on 07/16/18 at 4:20 PM. Patient #4 was found on the floor next to his/her bed on his/her right side. Patient #4 stated he/she was going to the bathroom and lost his/her footing and fell. There was no documentation in the nurses' notes in regard to the patients fall for 07/16/18 from 7:00 AM to 7:00 PM or from 7:00 PM to 7:00 AM the next day.

Interview with Staff C on 09/19/18 at 9:20 AM revealed he/she worked from 7:00 AM to 7:00 PM on 07/16/18. Staff C revealed that the behavioral health tech (BHT) called out and said Patient #4 was on the floor in his/her room. Staff C revealed when he/she arrived to Patient #4's room the patient was on the floor on his/her right side beside the bed. Staff C also revealed he/she documented the patient's fall in the nurses' notes. Staff C did not know why the notes regarding Patient #4's fall were not in the medical record.