HospitalInspections.org

Based on observation, interview, record review and policy review, the facility failed to ensure staff initiated a nursing care plan based on patient Fall Risk Assessment that included measurable goals and interventions for four current patients (#8, #9, #14 and #15) of seven current patients whose records were reviewed and one discharged patient (#2) of one discharged patient whose record was reviewed. This failed practice had the potential to affect all patients admitted to the facility when fall risks were identified but not addressed in the Care Plan. The facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Care Planning," dated 06/12, showed direction for staff to initiate care plan goals and interventions for all patients identified as a fall risk.

Record review of the facility's policy titled, "Fall Prevention Program," dated 04/2015, directed that precautions shall be implemented if the patient has been identified as a fall risk based upon nursing documentation or at the discretion of the nurse.

2. Observation in the Medical Surgical (M/S) Nurse Station on 06/09/15 at 10:30 AM of the Patient Care Huddle (a daily conference with physicians, nurses, case management, pharmacy, physical therapy, and others to discuss patient issues) showed a white board with the names of all current in patients listed. If a patient had been identified as a fall risk a yellow magnet was placed by the patient name. Seven patients (#8, #9, #10, #14, #15, #16, and #17) had the yellow magnet by their name. All of these patients were confirmed as a fall risk during the discussions.

3. Record review of current Patient #8's Physician History and Physical dated 06/07/15 showed that the patient was admitted to the facility on 06/07/15 for pneumonia (lung infection), shortness of breath, weakness and congestive heart failure (CHF, fluid around the heart).

Record review of Patient #8's Adult Shift Assessment dated 06/07/15 showed that the patient was identified as a High Fall Risk.

Record review of Patient #8's Care Plan on 06/09/15 showed that no goals or interventions were identified related to fall risk, even though the patient had been identified as a fall risk on the white board.

During an interview on 06/09/15 at Noon, Staff G, Registered Nurse (RN), stated that sometimes the fall risk care plan was missed because it doesn't fill in automatically (in the electronic medical record) based on the diagnosis (some care plan interventions and goals were generated automatically based on the patient's admission diagnosis).

4. Record review of current Patient #9's Physician History and Physical dated 06/08/15 showed that the patient was admitted to the facility on 06/07/15 for chest pain, Chronic Obstructive Pulmonary Disease (COPD, lung disease causing shortness of breath) and fever. Patient #9 had a history of stroke and seizures.

Record review of Patient #9's Care Plan on 06/09/15 at 11:00 AM showed no goals or interventions related to fall risk, even though the patient had been identified as a fall risk on the white board.

During an interview on 06/09/15 at 9:30 AM Patient #9 stated that she was not able to get up or walk by herself; she needed to be assisted.

During an interview on 06/09/15 at 11:10 AM Staff H, nursing informatics specialist, confirmed that no care plan entries had been made for Patient #9
related to fall risk.

5. Record review of current Patient #14's Physician History and Physical dated 06/03/15 showed that the patient was admitted to the facility on 06/03/15 for anemia (low blood count), infected ureteral stent (device placed into a tube between the kidney and the bladder) to help urine flow, and weakness. Patient #14 had a history of diabetes, dementia (memory loss), stroke, and heart attack.

Record review of Patient #14's Adult Shift Assessment on 06/06/15 showed that the patient was identified as a High Fall Risk.

Record review of Patient #14's Care Plan on 06/10/15 at 11:20 AM showed no goals or interventions related to fall risk, even though the patient had been identified as a fall risk on the white board and by the Adult Shift Assessment.

During an interview on 06/10/15 at 11:25 AM Staff H stated that no care plan entries had been made related to fall risk.

6. Record review of current Patient #15's Physician History and Physical dated 06/07/15 showed that the patient was admitted to the facility on 06/06/15 for a right knee replacement.

Record review of Patient #15's Care Plan on 06/10/15 at 11:00 AM showed no goals or interventions related to fall risk, even though the patient had been identified as a fall risk on the white board.

During an interview on 06/10/15 at 11:10 AM Staff H stated that no care plan entries had been made related to fall risk for Patient #15.

During an interview on 06/10/15 at 4:15 PM Staff C, Chief Nursing Officer, stated that she knew that the care plan process related to fall risk assessment did not function well. She stated that the hospital had worked with the electronic medical record vendor but, "we had not finalized a solution".

During an interview on 06/09/15 at 12:30 PM, Staff E, Director of In-Patient Services, stated that the Care Plan related to fall risk was in chaos and it had not been fixed as yet. The big problem was that it didn't flow from the fall risk assessment to the Care Plan. He stated that the hospital worked with the vendor and was in the process to get it corrected.

7. Record review of discharged Patient #2's Physician History and Physical dated 03/31/15 showed that the patient was admitted to the facility on 03/31/15 for pneumonia and CHF. Patient #2 had a history of diabetes, dementia (memory loss), heart surgery and was on Coumadin (blood thinner).

Record review of Patient #2's daily fall risk assessments dated from 03/30/15 to 04/05/15 showed that the patient was identified as a high fall risk. On 04/06/15 the fall risk assessment was changed to, "not a high fall risk."

Record review of Patient #2's Care Plan from 03/30/15 to 04/07/15 showed no goals or interventions related to fall risk, even though the patient had been identified as a high fall risk based on assessment.

During an interview on 06/10/15 at 12:30 PM, Staff F, Director of Quality Improvement, stated that Care Plan goals and interventions for fall risks were never initiated for Patient #2 and that the patient was doing much better with walking and that was why the fall risk status was changed.


Record review of Patient #2's flow sheet showed that on 04/06/15 around 7:00 PM the patient fell.

Record review of physician's Discharge Summary dated 04/08/15 showed that Patient #2 suffered a head injury during the fall. The option to transfer the patient was discussed between the neurosurgeon (in St. Louis), the hospital physician and the patient's family. The family decided not to have the patient transferred and the patient expired on 04/07/15 at 6:24 AM.

During an interview on 06/10/15 at 12:30 PM, Staff F, Director of Quality Improvement, stated that Care Plan goals and interventions for fall risks were never initiated for Patient #2.