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Based on policy review, medical record review, document review, and staff interview the hospital failed to ensure nursing services had a system in place to ensure patients at risk for falls were properly assessed and appropriate interventions were implemented to prevent falls and injury for 3 of 10 sampled patients (Patient 1, 8 and 9).

The cumulative effect of this deficient practice has the potential to place patients at risk for harm, severe injury or death.

Findings Include:

Hospital policy titled, "Fall or Injury/Disruption of Care, Care of the Patient at Risk for/Who Has Sustained a Fall" with an effective date of 08/01/18, showed staff are to initiate this protocol for adult patients that score 45 or greater on the Morse Fall Risk assessment tool, or, adult patients who are confused and demonstrate impaired judgement and lack of safety awareness. The policy shows at Prevention Interventions section 1, "Provide and document patient/family education regarding fall prevention and Fall Risk Agreement. Section 2. Consider any of the following interventions based on patient's risk. 2. D. Apply alarms/alerts such as: Yellow armband required for patients with a Morse score of greater than 45, Humpty Dumpty greater than 12. Yellow nonskid slipper socks, bed/and or chair alarm, fall risk magnet/signage on doorway, side rails (1-3), call for assistance signage in bathroom".

Document review of the "Morse Fall Risk Tool" showed that staff assign 0 to 125 points based on responses to six questions. 1. Does the patient have a history of falling; immediate or within the past three months? 2. Does the patient have a secondary diagnosis? 3. Does the patient use ambulatory aids such as crutches, cane, walker or furniture? 4. Does the patient have IV medications or a heparin lock? 5. Does the patient have an impaired or weak gait or ability to transfer? 6. Does the patient have a decreased mental status such as forgetting limitations? After answering all six questions if the points total more than 51 staff should implement high risk fall precautions.

Document review of the hospital's "Fall Log" showed in March 2019 there were 13 patient falls where the patients' fall risk was 60 or greater.


Review of Patient 1's discharged medical record showed he was admitted on 03/18/19 with a diagnosis of diarrhea, dehydration, gastroenteritis.

On 03/20/19 at 10:00 PM Staff I, Registered Nurse (RN), documented Patient 1's fall risk score as 75. Staff I, RN also documented that a fall alarm was on and there was close placement of assistive devices (walker).

Documentation on 03/21/19 at 3:10 AM showed Patient 1 fell, and staff found him on the floor.

Document review of the hospital's "Fall Log" showed on 03/21/19 at 3:10 AM, Patient 1 fell after getting up to go to the bathroom on his own. Pad (Bed Alarm) not connected to the box.
Document review of the hospitals "Fall Prevention Self-Reflection Tool" completed by Staff I, RN, showed factors that could have increased the risk of falling included bed alarm detached, impaired judgement, patient very weak, and patient has tremors. What could have been done differently included attaching the bed alarm at base.


Review of Patient 8's discharged medical record showed he was admitted on 04/22/19 with a diagnosis of a fall, sepsis, and a wound infection.

Patient 8 had been admitted after a fall at home and was "profoundly weak" and confused, had fall risk scores above 60 each shift since admission. However, nursing staff failed to utilize appropriate fall risk precautions.

On 04/24/19 at 4:00 AM, Staff P, RN, documented in the medical record that the primary nurse was off the unit on lunch break at the time of the patients fall. Staff P, RN, found Patient 8 on the floor with a bleeding head, she applied dressings, and had the patient transported to the emergency department for further evaluation and treatment.

During an interview on 05/13/19 at 4:30 PM, Staff D, Medical Surgical Unit Manager, stated, "this fall was preventable". Staff D, stated that if the nurse had gotten a better handoff at shift change or if Staff P, RN, had reviewed the medical record earlier in the shift this probably wouldn't have happened.


Review of Patient 9's discharged medical record showed she was admitted on 03/08/19 with a diagnosis of a urinary tract infection, dementia (a decline in memory or thinking skills), and hypertension (high blood pressure).

On 03/08/19 at 10:00 AM, Staff Q, RN, documented in the medical record that Patient 9 ambulated in hall using assistance from two staff members. Staff Q, RN, documented that she notified the emergency department provider that Patient 9 was unsteady while ambulating.

On 3/08/19 at 12:00 PM, Staff Y, RN, documented in the medical record the following fall risk precautions implemented: Bed/crib in low position, Bed wheels locked, Call device within reach, patient overestimates or forgets limitations, rounding every 1-2 hours, including position, toileting, Continent of urine, Continent of stool, ID band check, Non-slip footwear, a fall risk band, fall risk indicator on the door. Staff Y, RN, also reported the patient was disoriented/confused and their family or companion was not available.

On 03/08/19 at 7:00 PM Staff R, RN, documented the fall risk score as 50. The following factors contributed to the score: overestimates or forgets limits, IV access, and a presence of secondary diagnosis. Staff R, RN, had also documented the patient was confused at that time.

On 03/09/19 at 3:00 AM (Falls Documentation Note) by Staff R, RN, showed the patient got out of bed and grabbed the curtain in the room to hang on to and the curtain came undone and her and the curtain fell to ground.

During an interview on 05/13/19 at 12:15 PM, Staff I, RN, stated that a fall risk score of 60 would require staff to use a bed alarm for patients but it is the nurse's judgement to use it even if the score is lower.

(Refer to Tag A0395)

Based on policy review, document review, medical record review and staff interview the hospital failed to ensure staff followed patient safety policies and procedures by ensuring activation of safety devices and alerts for 3 of 10 sampled medical records reviewed (Patients 1, 8, and 9) .

The nursing staff's failure to ensure activation of safety devices and alerts has the potential to increase the risk of patient falls and injuries.

Findings Include:

Hospital policy titled, "Fall or Injury/Disruption of Care, Care of the Patient at Risk for/Who Has Sustained a Fall" with an effective date of 08/01/18, showed staff are to initiate this protocol for adult patients that score 45 or greater on the Morse Fall Risk assessment tool, or, adult patients who are confused and demonstrate impaired judgement and lack of safety awareness. The policy shows at Prevention Interventions section 1, "Provide and document patient/family education regarding fall prevention and Fall Risk Agreement. Section 2. Consider any of the following interventions based on patient's risk. 2.D. Apply alarms/alerts such as: Yellow armband required for patients with a Morse score of greater than 45, Humpty Dumpty greater than 12. Yellow nonskid slipper socks, bed/and or char alarm, fall risk magnet/signage on doorway, side rails (1-3), call for assistance signage in bathroom".

Document review of the "Morse Fall Risk Tool" showed that staff assign 0 to 125 points based on responses to six questions. 1. Does the patient have a history of falling; immediate or within the past three months? 2. Does the patient have a secondary diagnosis? 3. Does the patient use ambulatory aids such as crutches, cane, walker or furniture? 4. Does the patient have IV medications or a heparin lock? 5. Does the patient have an impaired or weak gait or ability to transfer? 6. Does the patient have a decreased mental status such as forgetting limitations? After answering all six questions if the points total more than 51 staff should implement high risk fall precautions.

Review of Patient 1's discharged medical record showed he was admitted on 03/18/19 with a diagnosis of diarrhea, dehydration, gastroenteritis. Patient 1 was admitted to the medical/surgical unit and placed in room 321.

On 03/20/19 at 10:00 PM Staff I, Registered Nurse (RN), documented Patient 1's fall risk score as 75. Staff I, RN also documented that a fall alarm was on and there was close placement of assistive devices (walker).

Documentation on 03/21/19 at 3:10 AM showed Patient 1 fell and staff found him on the floor.

Further documentation showed there were no other people in the room at the time of the fall.

Post Fall: X-ray showed a trans-cervical left femoral neck fracture (left hip fracture).

Document review of the hospital's "Fall Log" showed on 03/21/19 at 3:10 AM, Patient 1 fell after getting up to go to the bathroom on his own. Pad (Bed Alarm) not connected to the box. The patient was taking Flomax (a medication used to treat an enlarged prostate and may cause a sudden drop in your blood pressure, which could lead to dizziness or fainting), hydralazine (a medication used to treat high blood pressure and may cause dizziness, disorientation, or anxiety). And Xanax (a medication used to treat anxiety and the sedative effects of Xanax may last longer in older adults. Accidental falls are common in elderly patients who take benzodiazepines).

Document review of the hospital's "Post Fall debriefing" for Patient 1 showed Staff I, RN was the nurse assigned to Patient 1 during the night of 03/20/19 - 03/21/19. Staff I, RN, reported "Patient got up on his own and did not use his call light to call for assistance" and "Bed alarm cord was found detached from box".

Document review of the hospitals "Fall Prevention Self-Reflection Tool" completed by Staff I, RN, showed factors
that could have increased the risk of falling included bed alarm detached, impaired judgement, patient very weak, and patient has tremors. What could have been done differently included attaching the bed alarm at base.

During an interview on 05/10/19 at 12:15 PM, Patient 1's family member stated that while Patient 1 was in the hospital and on fall precautions he got up in the night to go to the bathroom without his walker, he uses a cane at home, and fell. He suffered a broken hip because of the fall. The family member stated that she was told that Patient 1's primary nurse, Staff I, RN, was taking a lunch break when the fall happened. She stated that hospital staff told her that the bed alarm did not go off because someone had unplugged it. She stated, "They told me that they didn't know who unplugged it or how it came unplugged".

During an interview on 05/13/19 at 12:15 PM, Staff I, RN, stated, "I don't know how or why the bed alarm was unplugged. I have tried to figure it out". Staff I, RN, stated that Patient 1 had rolled around in the bed and the alarm went off, so she knew it was working earlier in the shift before she went to lunch. Staff I, RN, stated that a fall risk score of 60 would require them to use a bed alarm for Patient 1. Staff I, RN, stated that when she came back from lunch another nurse had walked past Patient 1's room and said, "he is on the floor" and she went in to help him and called the Fall Investigation Team (FIT), the unit manager, the doctor, and the patients family member.

During an interview on 05/13/19 at 1:00 PM Staff T, RN, stated that she covered the lunch break for Staff I, RN. Staff T, RN, stated that she had not gone into Patient 1's room prior to the fall because he had not used his call light and his alarm did not go off. Staff T, RN, stated, "Staff I, RN, was very busy that night with her patients. When she went to lunch she gave me her pager, but we don't really do a handoff for lunches, so I didn't know his history or if he was a fall risk." Staff T, RN, stated that when covering another nurse's patients, they just listen for alarms or the pager to go off otherwise they don't provide any care unless a patient request something. Staff T, RN, stated that caring for her assigned patients kept her busy and she was covering Staff I, RN's, patients too and they were total patient care. Staff T, RN, stated, "I don't think we were adequately staffed to cover lunches that night".


Review of Patient 8's discharged medical record showed he was admitted on 04/22/19 with a diagnosis of a fall, sepsis, and a wound infection. Patient 8 was admitted to the medical/surgical unit and placed in room 311.
Fall Risk Score on 04/22/19 recorded as 60, on 04/23/19 at 8:20 AM it was 75 and at 7:45 PM it was 60, on 04/24/19 recorded as 60 at 7:30 AM, 75 at 4:00 PM, 60 at 9:00 PM and 60 on 04/25/19 at 4:00 AM.

During an interview on 05/13/19 at 12:15 PM, Staff I, RN, stated that a fall risk score of 60 would require staff to use a bed alarm for patients but it is the nurse's judgement to use it even if the score is lower.

During an interview on 05/13/19 at 11:30 AM, Staff D, Medical Surgical Unit Manager, stated, "It is the expectation on the medical/surgical unit that if a patient has a fall risk score of 60 or more they have a bed alarm in use".
On 04/24/19 at 4:00 AM, Staff P, RN, documented in the medical record that the primary nurse was off the unit on lunch break at the time of the patients fall. Staff P, RN, found Patient 8 on the floor with a bleeding head, she applied dressings, and had the patient transported to the emergency department for further evaluation and treatment.
On 04/24/19 at 7:30 AM, Staff O, CNA, documented in the medical record that a bed alarm was in place and active. Staff did not document an active bed alarm again until 04/25/19 at 6:00 AM after the fall.

During an interview on 05/13/19 at 4:00 PM, Staff P, RN, stated, "the fall happened during my lunch break. I didn't do an egress (patients ability to get out of bed or ability to move) check because I assumed he would have failed it. Staff I, RN, didn't tell me in report that he had fallen at home or was able to move out of bed independently. I only knew that he was wheelchair bound. I think that is the reason why he did not have the alarm. If I had known about the fall at home I would have prioritized it as a risk". Staff P, RN, stated that she had not reviewed his medical record prior to going to lunch because, "from the start of the shift it was so busy that I didn't have time to look at the medical record. I should have at least looked at the fall risk score".

During an interview on 05/13/19 at 12:45 PM, Staff S, RN stated, "I was covering for someone who was at dinner. I knew Patient 8 was a paraplegic and Staff P, RN, told me he didn't get out of bed. A laboratory technician had gone in and drawn his blood for labs. The laboratory technician told me that Patient 8 wanted to talk to his nurse and I said that I would let Staff P, RN, know that he wanted to talk to her, but I didn't go in to check on him myself. Then a little bit later I heard him fall to the ground".

Review of document titled, "Fall Log" showed on 04/25/19 at 4:30 AM Staff P, RN, found Patient 8 on the floor. There was an egress (getting out of bed) failure. Medications given to Patient 8 prior to the fall included Buspar (an antianxiety medication which can cause muscle weakness, confusion, or uncontrolled movements of the body) at 9:00 PM, Neurontin (a medication used to treat nerve pain which can cause dizziness, drowsiness, or unsteadiness), at 9:37 PM, Norco (a pain medication which can cause drowsiness or confusion) at 11:38 PM, and Dilaudid (a pain medication that can cause drowsiness or confusion) at 11:55 PM. No bed alarm was in place.

Review of document titled "Post Fall Briefing Report" dated 04/25/19 at 4:30 AM showed Staff P, RN, was Patient 8's primary nurse and that Staff P, RN, did not identify Patient 8 as a fall risk prior to the fall.
Additional documentation in the medical record showed the patient was not wearing an armband and staff did not post fall signage. Patient 8's fall risk was not discussed at handoff or during the shift change huddle.

During an interview on 05/13/19 at 1:30 PM, Staff T, RN, stated that an egress test is a test of the patient's ability to move out of bed.

During an interview on 05/13/19 at 4:30 PM, Staff D, Medical Surgical Unit Manager, stated, "this fall was preventable". Staff D, stated that if the nurse had gotten a better handoff at shift change or if Staff P, RN, had reviewed the medical record earlier in the shift this probably wouldn't have happened.

Patient 8 had been admitted after a fall at home and was "profoundly weak" and confused, had fall risk scores above 60 since admission. However, nursing staff failed to utilize appropriate fall risk precautions.


Review of Patient 9's discharged medical record showed she was admitted on 03/08/19 with a diagnosis of a urinary tract infection, dementia (a decline in memory or thinking skills), and hypertension (high blood pressure). Patient 9 was admitted to the medical/surgical unit in room # 342.

On 03/08/19 at 10:00 AM, Staff Q, RN, documented in the medical record that Patient 9 ambulated in hall using assistance from two staff members. Staff Q, RN, documented that she notified the emergency department provider that Patient 9 was unsteady while ambulating.

On 3/08/19 at 12:00 PM, Staff Y, RN, documented in the medical record the following fall risk precautions implemented: Bed/crib in low position, Bed wheels locked, Call device within reach, patient overestimates or forgets limitations, rounding every 1-2 hours, including position, toileting, Continent of urine, Continent of stool, ID band check, Non-slip footwear, a fall risk band, fall risk indicator on the door. Staff Y, RN, also reported the patient was disoriented/confused and their family or companion was not available.

On 03/08/19 at 7:00 PM Staff R, RN, documented the fall risk score as 50. The following factors contributed to the score: overestimates or forgets limits, IV access, and a presence of secondary diagnosis. Staff R, RN, had also documented the patient was confused at that time.

On 03/09/19 at 3:00 AM (Falls Documentation Note) by Staff R, RN, showed the patient got out of bed and grabbed the curtain in the room to hang on to and the curtain came undone and her and the curtain fell to ground.
X-ray showed evidence of displaced right intertrochanteric femur fracture. The provider requested a consult with an orthopedic surgeon. She underwent open reduction and internal fixation (surgical repair) with a trochanteric fixation nail on 03/09/19.

Document review of the "Fall Log" showed on 03/09/19 at 3:00 AM showed Staff R, RN, found Patient 9 on the floor. The patient woke up and got up to go to the bathroom then she grabbed a curtain along the way and it came down and she fell. Medications given prior to the fall included Seroquel (a medication used to treat mental/mood disorders and can cause cognitive or motor impairments) at 6:37 PM and Neurontin (a medication used to treat nerve pain which can cause dizziness, drowsiness, or unsteadiness) at 10:13 PM. No bed alarm was in place.

Document review of the "Fall Prevention Self-Reflective Tool" dated 03/08/19 showed Staff N, RN stated, "patient steady and alert and oriented, paged appropriately (used her call light when needing to get up and go to the bathroom), and had been walking all day in hall".

During an interview on 05/15/19 at 9:00 AM, Staff R, RN, stated that she thought the patient had a history of dementia or being confused. Staff R, RN, stated, "It's been a while since I had Patient 9, but I thought we did have a bed alarm for her. I think we were running to her room because of the alarm and then heard her fall. I am not sure I am remembering it right". Staff R, RN, stated that Patient 9 did not have a walker or cane and staff helped her to the bathroom with a gait belt. Staff R, RN, stated that she did not know why the documentation in the chart stating the patient was confused was not the same as what she wrote on the "Fall Prevention Self-Reflective Tool". Staff RN, RN stated that the patient, if she remembered right, was steady when walking in the hallway and not confused during her shift.

Document review of the hospital's "Fall Log" showed in March 2019 there were 13 patient falls where the patients' fall risk was 60 or greater.

During an interview on 05/13/19 at 2:30 PM, Staff B, Quality Director, stated at that time, unit staff did fall audits, but they were informal and not documented or staff threw the documentation away, so she could not confirm if lack of bed alarm use was related to each reported fall.

During an interview on 05/13/19 at 4:30 PM, Staff B, Quality Director, stated that she attributed some of the bed alarm failures to patients moving from the bed to a chair and a staff members failure to plug and unplug the correct pad into the alarm box on the bed alarms.

During an interview on 05/14/19 at 9:30 AM, Staff D, Medical Surgical Unit Manager, stated that staff should check that the alarm is properly working wherever the patient is located before leaving the room.

During an interview on 05/13/19 at 3:45 PM Staff B, Quality Director, and Staff D, Medical Surgical Unit Manager, stated that they have not conducted observations of night shift lunch break handoffs or usage of fall precaution items. Staff D, stated that the charge nurse should be rounding on high fall risk patients and they now have a safety rounder to help with patients identified as a high fall risk. Staff D, stated that if the patient's nurse doesn't properly identify the patient as a high fall risk these precautions would not help prevent a fall.

During an interview on 05/14/19 at 1:30 PM, Staff W, RN, stated that she is a dayshift charge nurse and the charge nurses do not assign themselves to care for individual patients. She stated they assign each nurse a "lunch buddy" to ensure everyone knows who will be covering their lunch. Staff W, RN, stated that unless a pager goes off or a bed alarm sounds the lunch buddy would not likely make patient contact with those patients. Staff W, RN, stated they do not give a formal handoff during lunch breaks and only give details about potential immediate needs or if someone is a safety concern. Staff W, RN, stated that staffing isn't a concern and they could call the house supervisor or a float pool nurse or even page the manager if necessary for help on the unit during the day or night shift.

During an interview on 05/14/19 at 2:15 PM, Staff X, RN, stated she was a resource nurse and is on the unit during the day from about 1:00 PM until 9:30 PM. Staff X, RN, stated there is not a resource nurse after 9:30 PM. Staff X, RN, stated that she does help with a lot of the new patient admissions, so she knows about many of the patients on the unit even though the primary nurses don't give much patient information on all their patients when they go to lunch.

During an interview on 05/14/19 at 2:30 PM, Staff Y, RN, stated that if the bed alarms green light is on we assume that it is working properly. Staff Y, RN, stated that nursing staff does not have the patient move in the bed or stand up to make sure the alarm sounds to verify that it is working properly.