HospitalInspections.org

Based on clinical record review and staff interview, the facility failed to implement the prescribed services for a one to one sitter for 1 of 10 sampled patients (# 5). The facility also failed to update the care plan with interventions for the necessary supervision for Patient #5's assessed needs to prevent fall recurrence. The patient had multiple falls and subsequently sustained a fall with injuries which required transfer to another health care facility for treatment.

The findings include:

1) Review of the clinical record for Patient # 5 disclose the patient was admitted to the facility on 7/5/2012. The administrative records reveal the patient sustained four falls between 10/16 and 11/4/2012.

After the patient experienced an unwitnessed fall on 10/16/2012, the nurse documented 10/15/2012 at 11:00 PM, the patient was experiencing signs and symptoms of anxiety. Patient is "crying, demonstrating a short attention span and restless; "One to one monitor; Sitter at bedside if patient remains agitated trying to get out of bed. At 10:00 PM, the nurse wrote, not done, cancel this execution. Patient does not have a sitter." The facility's post fall plan is to initiate one to one monitoring. There is a physician order on 10/17/2012 for the patient to have 1:1 sitter. On 10/24/2012 at 8:46 AM, the patient experienced a second fall within 8 days. Fall assessment at 9:14 AM documented after the fall, indicates the patient is high risk for falls with a score of 19. At 10:0 AM a RN notes, "one to one monitor; sitter at bedside if patient remains agitated trying to get out of bed. This is followed by "Not done, cancel this execution, has been discontinued." Record review reveal there was no sitter present at the time of the patient's fall on 10/24/2012, despite the service being prescribed by the physician on 10/17/2012.

On 10/24/2012 the nurse documents "Potential for injury related to impaired thought process" on the updated plan of care. No nursing intervention were identified on this plan of care to manage the patient's elevated fall risk". On 10/25/2012 at 12:21 AM a telephone order was entered discontinuing the one to one sitter. There were no additional interventions developed and assessed to manage fall recurrent risk for the patient who had several recent falls previously.


On 10/26/2012 at 7:45 PM, the patient experienced a third fall in 2 days after the last fall.. The physician was notified and prescribed a one time dose of Xanax, and bilateral wrist restraints. The facility's investigative report notes the patient stated, she thought she could do it herself. The facility attributed the fall to the increased anxiety of the patient. There is no evidence the patient's care plan was updated with the facility's plan for the provision of services necessary for fall prevention supervision.

On 11/4/2012, the patient again fell, the patient's fourth fall since October. On this fall, the patient sustained injury to her face, and a hip fracture requiring transfer to another facility for care and services.

Review of the clinical record, nursing progress notes revealed documented, the patient had hand mitten restraints. The reason for the mitten was secondary to the patient pulling and disturbing medical equipment, including pulling tubes/lines, risk of injury to self due to inability to understand or remain oriented, poor judgment/fall risk, frequent attempts to get out of bed/chair. The patient is oriented to person, confused. Despite the identification of the above risk factors, the facility failed to develop and establish pertinent interventions to prevent or manage risks for fall recurrence.

During an interview on 11/29/2012 in the afternoon with the Nurse Manager she stated the patient had improved, and was becoming stronger and ambulated with assist. The patient did not like being left in the room and preferred being up in the chair. The patient did not have a sitter at the time of the fall. They felt the sitter was to be instituted if the patient was anxious and attempting to get out of bed. The Nurse Manager later reviewed the schedule and confirmed the patient did not have a sitter at the time of her falls. She also confirmed, the patient's judgment was impaired and she would think she could do more than she was capable of. She further confirmed, the patient was not provided a sitter until after the patient returned to the facility post hospitalization for hip fracture on the 4th fall.

Based on clinical record review and staff interview, the facility failed to update the nursing care plan to address the patient's assessed fall prevention needs for 1 of 10 sampled patients (# 5). The patient had multiple falls and subsequently incurred a fall with injuries which required transfer to another health care facility for treatment.

The findings include:

1) Review of the clinical record for Patient # 5 discloses the patient was admitted to the facility on 7/5/2012. The administrative records reveal the patient sustained four falls from 10/16 to 11/4/2012.

The patient experienced an unwitnessed fall on 10/16/2012 at 1:11 AM, when the patient fell from the bed. The patient was found on the left side of the bed, lying on her left side. There was no apparent injury. The fall assessment prior to the fall identified the patient as "not high risk for falls at this time with a fall score of 9" (a score of 10 or above indicates high fall risk). Safety assessment documents the following, bed in low position, call light in place, side rails times 2 and fall signage on door. The nurse documented on 10/15/2012 at 11:00PM, the patient was experiencing signs and symptoms of anxiety. Patient is "crying, demonstrating a short attention span and restless. Also documented is, "One to one monitor; Sitter at bedside if patient remains agitated trying to get out of bed." At 10:00 PM, "not done, cancel this execution." "Patient does not have a sitter."
The facility's post fall plan is to initiate one to one monitoring. There is a physician order on 10/17/2012 for the patient to have 1:1 sitter.

On 10/24/2012 at 8:46 AM, the patient experienced a second fall within 8 days. The patient had an unwitnessed fall and was found sitting on the floor at the bedside. "No apparent injuries noted." The patient did state, her "butt hurts". Fall precautions in place prior to the fall were: floor mats, bed in lowest position, side rails up times 2. The plan was to continue the precautions.
Review of the clinical record disclose an assessment was entered for 10/24/2012 at 8:45 AM however, there is no information documented. Fall assessment at 9:14 AM, documented after the fall, indicates the patient is high risk for falls with a score of 19. Documentation at 10:0 AM notes. "one to one monitor, sitter at bedside if patient remains agitated trying to get out of bed. "Not done, cancel this execution, has been discontinued."

On 10/24/2012 the nurse identified "Potential for injury related to impaired thought process" on the updated plan of care. The intervention identified on this plan of care is "Reassess fall risk". There were no actual interventions or approaches to care designed to manage risk factors for fall and recurrence documented on the care plan.

On 10/25/2012 at 12:21 AM a telephone order was entered discontinuing the one to one sitter. There were no notation or interventions on the Care Plan identifying the facility's approaches to prevent falls for this patient who had several recent falls.


On 10/26/2012 at 7:45 PM, the patient experienced a third fall in 2 days after her last fall. The physician was notified and prescribed a one time dose of Xanax and bilateral wrist restraints. The clincial record documents, The patient remains oriented to self only. The investigative report notes the patient stated, she thought she could do it herself. The facility attributed the fall to the increased anxiety of the patient. There is no evidence the patient's care plan was updated.

On 11/4/2012, the patient again fell, the patient's fourth fall since October. The patient sustained injury to her face and a hip fracture requiring transfer to another facility for care and services.

Review of the clinical record, nursing progress notes document the patient had hand mitten restraints and the reason for mitten is secondary to the patient pulling and disturbing medical equipment, including pulling tubes/lines, risk of injury to self due to inability to understand or remain oriented, poor judgment/fall risk, frequent attempts to get out of bed/chair. The patient is oriented to person, confused.

The 11/5/2012 physician progress note documented that the patient was seen and her chart reviewed. "Case discussed with staff in detail. The patient gets very irritable, agitated, tries to get out of bed. The patient fell and had a laceration on her head. The patient's CT scan shows no acute finding. Patient is lying in bed, does not follow any commands. Speech is mumbled, thought process distractible. Thought content was noted as poverty of content and impulse control is poor."
An updated care plan was not done.

During an interview on 11/29/2012 in the afternoon with the Nurse Manager she stated the patient had improved and was becoming stronger and ambulated with assist. The patient did not like being left in the room and preferred being up in the chair. The patient did not have a sitter at the time of the fall. They felt the sitter was to be instituted if the patient was anxious and attempting to get out of bed. Even after the physician evaluated and identified patient agitation, and trying to get out of bed was realized a sitter was not provided per policy and after a fall. The Nurse Manager later reviewed the schedule and confirmed the patient did not have sitter at the time of her falls. She further confirmed the patient's judgement was impaired and she would think she could do more than she was capable of, and said the patient did not have a sitter until after the patient returned to the facility after hospitalization for the hip fracture sustained on the 4th fall.