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Based on interview and record review, the hospital failed to ensure staff followed their fall policy and procedure for three of three sampled patients (Patients 7, 17, and 18) after their falls. This failure had the potential to result in patients' fall health complications for missing assessments.

Findings:

1. Review of Patient 7's record indicated the patient had a physician's order to give Lovenox (blood thinning medication with a side effect of bleeding) 40 milligrams (mg a metric unit of measurement) by injection daily and was administered the medication on 1/20/25 at 7:32 a.m.

Review of Patient 7's registered nurse note, dated 1/20/25 at 1:47 p.m., indicated at 1:40 p.m., the patient fell, hit her right head and hip, sustained a skin tear on the right elbow and was having hip pain.

Review of a physician's note, dated 1/20/25 at 1:57 p.m., indicated Patient 7 fell on the floor and had complaints of pain in right hip area.

Patient 7's record indicated there was no ongoing monitoring of vital signs (measurements such as heart and respiratory rate and blood pressure that show how well the body is working), neurological assessment (tool to detect any problems with the nervous system such as level of consciousness), brusing, and presence of pain after fall. Also, the patient's pain after the fall was not thoroughly assessed, i.e. pain rating between zero to ten was not documented.

Review of Patient 7's medication administration record, dated 1/20/25 at 5:19 a.m., indicated the patient received Norco (pain medication) 5-325 mg tablet to treat for moderate pain, three hours after her fall.

During an interview on 3/12/25 at 10:05 a.m., the nurse executive (NE) who reviewed the record confirmed Patient 7 was alert and oriented and stated there should have been a follow-up to ensure nurses followed hospital policy in performing post fall vitals signs, pain assessments, and neurological checks.

The Fall Prevention Guidelines, dated 2/23/22, under post fall management section for any fall with potential injury, indicated to monitor every 15 minutes for one hour the presense of injury such as fracture, bleeding through vital signs, presence of pain - location, intensity and duration, basic neurological assessment, range of motion of extremities and bruising.

The Pain Management policy, dated 2/27/25, indicated a basic meassure of pain intensity was from obtaining patients' self report using a pain rating scale (e.g. 0-10 scale) and the registered nurse was to continually assess and reassess the patient.

Review of Patient 7's Physician Discharge Summary, dated 1/25/25 at 10:14 a.m., indicated the patient fell on 1/20/25, had an acute right intertrochanteric fracture (a break in the thigh bone) and underwent surgical repair on 1/21/25.

2. Review of Patient 17's Medicine Progress Note, dated 1/12/25 indicated the patient presented to the emergency room with complaints of dizziness, nausea, and vomiting.

Review of Patient 17's Care Plan Addendum, dated 1/12/25 indicated on 1/12/25 at 1:37 p.m., the patient had an unwitnessed fall when she got up from her bedside commode and lost balance.

Review of Patient 17's flowsheets, dated 1/12/25 indicated vital signs were not monitored every 15 minutes for one hour. Patient 17's pain was first assessed at 5:04 p.m., more than three hours after she fell. Patient 17's pupil size, change of strength in extremity, and comparison of left to right movement and strength were also not monitored.

3. Review of Patient 18's ED Provider Notes, dated 1/18/25 indicated the patient presented with vaginal bleeding.

Review of Patient 18's ED Notes, dated 1/18/25 at 10:13 a.m. indicated the patient fainted and fell onto the floor after a laboratory blood draw.

Review of Patient 18's flowsheets, dated 1/18/25 indicated vital signs were not monitored every 15 minutes for one hour. The flowsheets also indicated Patient 18's change of strength in extremity and comparison of left to right movement and strength were not monitored.

During an interview on 3/20/25 at 3:34 p.m., the Quality Improvement Manager (QIM) confirmed the above findings for Patients 17 and 18.

Review of the hospital's policy, "Fall Prevention Guidelines," dated 2/23/2022 indicated post fall procedures for unwitnessed falls and any fall with potential injury include the following:
- Monitor vital signs every 15 minutes for one hour;
- Presence of pain - location, intensity, duration;
- Level of cousciousness and baseing neurological assessment including pupil size, change of strength in extremity, and comparison of left to right movement and strength.