HospitalInspections.org

Based on staff interview and record review nursing staff failed to conduct ongoing health assessments for Patient #6, in accordance with hospital policy. Findings include:

Per record review nursing staff did not conduct ongoing assessments, including measurement of V/S (vital signs) and neurological status, in accordance with the hospital's Post Fall Assessment & Management protocol, which stated, under the heading of Fall and Hits Head: Observations: "Institute vital signs and neurological observation and record every 30 minutes times 4, then every 1 hour times 4, then every shift times 24 hours." A nurse's note, dated 9/11/10 at 2:00 PM, stated that the patient had tripped while ambulating in the hall, fell against the wall then onto the floor, and had......."small, dime-sized egg on the top of....head". The nurse's note further stated that a physician assessed the patient and the patient was monitored and showed no signs of pain. However, the only V/S noted were documented at 3:42 PM, and although they included a BP (blood pressure) reading of only 85/65, there is no evidence of further assessment of V/S until greater than 4 hours later, on 9/12/10 at 8:05 AM, at which time the BP was recorded as 140/71.

A subsequent nurse's note, dated 9/16/10 at 4:01 AM, stated that the patient was found lying on the floor at 3:25 AM and stated that the patient had fallen and banged his/her head..........."has large bump on the back of.....head up towards the crown approximately 2 inches in diameter." Although V/S were documented at that time there are no other V/S documented until 6 hours later at 9:30 AM. In addition there was no evidence of ongoing neurological assessment, per the policy, following either of the falls.

During interview, on the afternoon of 12/1/10, the Unit Nurse Manager confirmed that staff failed to complete the V/S and neurological assessments in accordance with hospital policy.