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Based on record review, interview, and observation, the facility failed to ensure nursing staff implemented fall safety interventions for fall prevention for 7 of 14 patients (P-1, P-5, P-6, P-7, P-8, P-9 and P-14) resulting in harm to 2 patients (P-1, and P-14) and the potential for harm for all patients served by the facility who are at risk for falls. Findings include:

See Specific Tag: A-0392

Based on record review, interview, and observation, the facility failed to ensure nursing staff implemented fall safety interventions for fall prevention for 7 of 14 patients (P-1, P-5, P-6, P-7, P-8, P-9 and P-14) resulting in harm to 2 patients (P-1, and P-14) and the potential for harm for all patients at the facility who have a high risk for falls. Findings include:

Documentation review of P-1 medical record occurred on 7/18/2024. According to documentation P-1 sustained a fall on 6/16/2024 at 2057 on the Ortho/Neuro unit (C-2).

On 7/18/2024 at 1430, an interview was conducted with staff Q, registered nurse who cared for P-1 on 6/16/2024 at the time of the fall. Staff Q was asked if fall precautions for P-1 were in place. Staff Q stated "yes." Staff Q stated she was not in the room at the time of the fall. Staff Q stated that P-1 was found on the ground. Staff Q also stated that P-1's mother had left to go home, and that P-1 was in the room alone. Staff Q was then asked if P-1's bed alarm was activated when P-1 fell. Staff Q stated that the bed alarm was not functioning at the time of the fall. Staff Q was then asked if the chair alarm was in the bed at the time of the fall. Staff Q stated that the chair alarm was put in P-1's bed by the House Supervisor after P-1 fell. Staff Q was queried if it was known that the bed alarm was not working prior to P-1 falling. Staff Q stated, "No." Staff Q was then asked who was notified post fall event. Staff Q stated that she had called the house supervisor, staff N, P-1 physician, staff V, and P-1 mother. Staff Q stated that P-1 underwent CT scans after the fall. A nursing note by staff Q on 6/16/2024 at 2100 revealed the following, "Patient had unwitnessed fall and was found on floor by this RN. Charge nurse notified. House supervisor notified. Vital signs checked. Vital signs stable. Skin check was done. Scattered abrasions noted and bump to right side head noted on assessment. MD notified of event. Mother (name) notified of event. Full head to toe assessment done on patient. Will notify MD with any changes."

Based on medical record review, on 6/16/2024 at 2123, CT of the cervical spine and brain were completed. The indication for the CT scans stated, "ground level fall from bed." Findings resulted on 6/16/2024 at 2309. Findings were significant for "Intracranial Hemorrhage: Mild acute subarachnoid hemorrhage in the medial right parietal sulci." A repeat CT of the brain was completed on 6/17/2024 at 0925. Findings were noted as, "Stable trace subarachnoid blood products within the medial left parietal sulci." On 6/18/2024 at 1357 an X-ray of the right elbow was completed for right elbow swelling. Findings documented as, "no displaced fracture or dislocation ...there is soft tissue swelling." On 6/18/2024 at 1356 an X-ray of the right shoulder was completed. Indication for the x-ray was "fall, right shoulder bruising." Findings documented as, "No acute fracture or dislocation involving the right shoulder."

During the record review of P-1's medical record, documentation revealed that on 6/14/2024 at 2327 the following was documented, "Universal Fall Risk interventions; Bed/Chair alarm (consider plugging chair alarm into call light system and volume on high) ..." On 7/18/2024 at 1300 an interview occurred with staff A, the Manager of Patient Safety and Quality. Staff A was queried about P-1's fall on 6/16/2024. Staff A stated that during the investigation of P-1's fall, it was revealed that P-1's bed alarm did not work due to P-1's weight not being heavy enough to trigger the bed alarm. Documentation of first use of chair alarm on bed was on 6/17/2024 at 0046 (after P-1's fall) by staff N, house supervisor.

During interview on 8/1/2024 at 1310 Staff A was queried why the Morse Fall assessments were only documented four times in P-1 medical record. Staff A stated that Morse Fall assessments are used initially on admission of a patient to the facility up to 24 hours. Staff A explained that the EMR (electronic medical record) gathers information from documentation during the course of the patient's hospital stay and a Predictive Fall model score is assigned to the patient

On 7/18/2024 a document review occurred of the policy titled, "System Nursing G-07 Fall Prevention and Management Policy & Procedure," no date provided. According to the policy it states under, "Fall Prevention Standard Work, Assess patient: Complete and document a new Morse Fall Scale and Score: upon admission, during first 12 hours of admission, after treatment/procedure with sedation or anesthesia. Use Morse Fall Score to guide interventions: < 50: use Universal precautions interventions and any additional from moderate or high risk level as needed, = 50: use High Risk precautions interventions and consider Fall Watch level. Key Point: Why, Assessment with Morse Fall Scale at these required times supplements predictive model scoring during data generation upon arrival and recovery from anesthesia or sedation ...Patients post sedation are at risk due to lack of safety awareness and/or transitory deficits in sensation and ability to bear weight (altered mobility). The Morse Fall Scale is an evidence-based approach to help determine the risk for fall."

The Fall Prevention Flowchart describes "Low Risk" interventions as "Universal Interventions Includes all patients FPM (Fall Predictive Model) score 0 - 33 includes the following interventions, "orient to room / call light, call light in reach, bed low and locked, personal items in reach, adequate lighting, TEMP rounding, fall prevention screening, fall prevention education, call to stop a fall sign, room free form clutter, and Individualized interventions."

"Moderate Risk" includes FPM score 34 - 68 includes the following interventions, "All Universal interventions, yellow armband, fall precautions sign outside door, staff stay with patient during elimination, consider gait belt use."

"High Risk" includes FPM score >68 includes the following interventions, "All Universal and Moderate Fall Risk Interventions, Bed Alarm/Chair Alarm (consider plugging chair alarm into call light system and volume on high include signage as applicable, use gait belt for ambulation, assess need for video surveillance, assess need for Fall Watch Status."

According to the documentation for Fall Predictive Model, P-1 was not documented as a high risk fall although diagnoses included developmental delay of an 18-month-old, mental retardation, autism, and seizure disorder. According to the Morse Fall assessment P-1 was not considered high risk for falls. P-1 did not have a documented history of falling (score - 0), had a secondary diagnosis (score 15), intravenous therapy/saline lock (score 20), gait weak according to assessment and was receiving PT while hospitalized (score 10), Mental status - Overestimates / Forgets limitations as a bed/chair alarm was in use and P-1 has Developmental Delay, Mental Retardation, and Autism Diagnoses (score 15) - Total score 60. According to the Morse Fall assessment scale P-1 should have been a high risk for falls based upon the information in P-1 EMR. The following scoring is used to determine risk of falls:



Score Risk

0 No risk for falls

< 25 Low risk

25 - 45 Moderate risk

>45 High risk

"Morse Fall Risk Score table" - Tool 3H: Morse Fall Scale for Identifying Fall Risk Factors. Content last reviewed July 2023. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/morse-fall-scale.html.

The facility failed to provide interventions for P-1 based upon failure to accurately score the patient, and failure of the Fall Predictive Model to accurately score the P-1.

On 7/18/2024 at 1110 during a tour of the CCU (Critical Care Unit) observation of P-5 with a fall risk sign outside of room. Record review of P-5 medical record occurred on 7/18/2024. P-5 was admitted to the hospital on 7/9/2024 for acute respiratory failure with hypoxia. According to P-5 first Morse Fall assessment on 7/9/2024 at 2141, P-5 was scored a 55, high risk for falls. On 7/10/2024 interventions noted a "yellow armband" as an intervention to alert staff of P-5 being a fall risk. P-5 failed to have an armband.

On 7/18/2024 at 1118 during the tour of the CCU, observation of P-6 revealed a fall risk sign outside of the room. Record review of P-6 medical record occurred on 7/18/2024. P-6 was admitted to the facility on 7/13/2024 for blood in the urine. P-6 Morse Fall Risk score was 60 (high risk). P-6 was scored a "moderate" fall risk on 7/14/2024 at 1001. On 7/14/2024 at 1249 interventions included a fall risk "yellow armband" as an intervention to alert staff of P-6 being a fall risk. P-6 was observed and did not have a yellow armband.

On 7/18/2024 at 1125 during the tour of the CCU, observation of P-7 with a fall risk sign outside of the room. Record review of P-7 medical record occurred on 7/18/2024. P-7 was admitted to the facility on 7/17/2024 for chest pain. P-7 predictive model for falls was scored at 58.1. On 7/18/2024 at 0016 P-7 was noted to be a "moderate" fall risk. Interventions listed included a fall risk "yellow armband" as an intervention to alert staff of P-7 being a fall risk. P-7 was observed and did not have a yellow armband.

On 7/18/2024 at 1132 during the tour of the CCU, observation of P-8 with a fall risk sign outside of the room. Record review of P-8 medical record occurred on 7/18/2024. P-8 was admitted to the facility on 7/12/2024 with the chief complaint of "fall with injury." P-8 was documented as having acute altered mental status, hyperglycemia, and hematuria. Further documentation included "patient confused and not making sense...unable to state date and month." On 7/12/2024 at 1041, P-8 Morse Fall score documentation revealed P-8 was oriented to own ability, and not having a secondary diagnosis. P-8 initial Morse Fall Score on 7/12/2024 at 1041 was incorrect at 45. P-8 Morse Fall Score should have been 60 at his initial screening. P-8 presented to the facility related to a fall, had a secondary diagnosis, had an IV, and was not oriented to his own ability. On 7/12/2024 at 1041, "fall prevention/watch interventions" included yellow armband. P-8 failed to have a "yellow armband" as an intervention to alert staff of P-8 being a fall risk at the time of observation.

On 7/18/2024 at 1140 during a tour of the CCU, P-9 room had a fall risk sign outside of the room. P-9 was not on the unit at the time of tour but was in dialysis. On 7/18/2024 at 1140 P-9 was observed in the dialysis treatment area while on C-2 (Ortho-Neuro Unit). Record review of P-9 medical record occurred on 7/18/2024. P-9 was admitted to the facility on 7/12/2024. P-9 chief complaint was fever. P-9 was diagnosed with cholecystitis, pericardial effusion, and sepsis. P-9 initial Morse Fall Risk score was 65 on 7/12/2024 at 1343. P-9 Predictive model score for risk for fall 6.95 on 7/12/2024 at 1401. On 7/13/2024 at 1127 fall risk interventions included "yellow armband" as an intervention to alert staff of P-9 being a fall risk. P-9 was noted not to have a yellow armband.

On 7/19/2024 P-14 was identified as a moderate injury from a fall on 7/2/2024. Record review of P-14 medical record revealed P-14 was admitted to hospital on 7/2/2024 at 0602 for total knee replacement with a diagnosis of loosening of prosthesis. P-14 was transferred to unit C-2 on 7/2/2024 post surgery. P-14 first Morse fall assessment was completed on 7/2/2024 at 0609. P-14 score was 35. A second morse fall risk assessment was completed on 7/2/2024 1228. The second score was 60. A third morse fall risk was completed on 7/2/2024 at 1652 and P-14's score was 75.

On 7/2/2024 P-14's fall risk intervention list included "Do not leave alone during elimination."

P-14's medical record revealed on 7/2/2024 around 1500 P-14 fell in the bathroom while alone. P-14 fall caused dehiscence of the surgical wound requiring additional surgery and was transferred to surgery at 1641. P-14 underwent surgery for debridement and closure of the wound at 1708. P-14 was transferred back to C-2 at 1938.

On 7/3/24 at 1254 Physician, staff X documented the following at 1257, "Patient with a complicated postop recovery, was originally going to be a same day surgery, had difficulty with buckling so was changed to stay overnight for more physical therapy before discharge. Patient was up into the bathroom (on Ortho/Neuro unit) when her surgical leg gave out and she fell to the floor causing her surgical incision to dehisce, patient was taken back to surgery for I&D and reclosure of wound. This morning patient doing well, discussed concerns for postoperative infection and the increased risks for it following the dehiscence."

On 7/19/2024 at 1010 an interview was conducted with staff L, Outcome Coordinator for Patient Safety and Quality. Staff L was asked what action plans were implemented to address falls in the facility. Staff L explained a "Kaiser" study had been completed at a system level. Staff L also stated that "TEMP" rounding had been implemented and started in May of 2024. Staff L explained "TEMP" rounding included rounding on patients to check for toileting, placing the call light within reach, placing necessary items within reach, check that the bed is in low position and locked, check bed/chair alarms are on, assess patient's position in bed and comfort, ensure the patient is repositioned every two hours, and assessing patient's pain level using a pain scale. Staff L further stated that two admission nurses had been hired to help with patient admissions as part of the Fall reduction project.

Review of falls for the facility failed to show a decrease in falls since the implementation of "TEMP" rounding and the addition of admission nurses.