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Based on record review and interview the facility failed to follow its own policy regarding fall assessment for 1 of 20 (pt. #1 of #1-#20) after a fall. Staff #4 failed to document neurological assessment of patient #1 after sustaining an unwitnessed fall.

On 4/8/2015 at 10:30 in the conference room the medical record (MR) for patient (Pt/pt.) #1 was reviewed with the assistance of the Director of Nurses, and revealed the following: Pt #1 was an 83 year old man, status post old stroke, with right sided hemiplegia. On 2/13/2015, upon his arrival to the Emergency Department, he was alert, oriented and able to clearly make his needs known. He was admitted to the acute nursing unit after it was determined his heart was in Atrial Fibrillation. On the inpatient unit, the receiving nurse assessed pt. #1, to have a high risk for fall, scoring 110.

Further review of pt. #1 medical record (MR) reveled the nurse documented the following interventions were implemented to protect pt. #1 from falling. Pt #1 was placed in a room near the nurse ' s station with a safety alarm in place, side rails up times two and the door left open. The nursing interventions were identified for a patient with a fall risk score of 25-44. Pt #1's fall risk score was 110.

Further review of pt. #1 MR revealed, at 10:39 Registered Nurse (RN) #4, documented a narrative summary of events which took place during his 12 hour shift on 2/14/15 The entire narrative reads as follows: "Pt had fallen on 2/14/25 at 17:18 (5:18 p.m.) and was found on the floor in the room with his meal tray on top of him. Pt reported no injuries and assessment revealed pt's neurological status to be WNL (within normal limits) and no physical injuries assessed. Physician contact was initiated and physician #7 requested that a brain CT (Computerized Tomography) to be completed in AM (Morning) on 2/15/15 unless a variance from baseline was assessed. The patient was in bed with side rails up times two, bedside table over the pt. to eat dinner, pt. safety alarm was activated, and the pt's door was open near the nurse ' s station. Prior to the pt. fall the pt. had become increasingly anxious and agitated that he was no (sic) going home soon and we tried to explain to him that he would be here until he received his ECHO that is scheduled for Monday 2/16/2015. The pt. was brought to the nurses station to be monitored d/t (due too) his anxiety and combativeness and remained called (sic) through the day. Following shift change the pt. was returned to his room to prepare for bed and he became very combative and was attempting to swing at staff. Attempts were made to calm the pt. but the pt. refused to comply with any medication administration or assessment. The Pt's hostility increased to the point that we had to call the physician to receive and (sic) order for some form of sedation. The pt was medicated with the ordered one time doses. During the episode the pt's IV (intravenous access) became infiltrated and bloody and was D/C ' d (discontinued). Family was called to help calm the pt. Pt family arrived and aided in the resolution of the conflict and the pt. is currently resting peacefully in the room with family at this time. Post fall huddle completed. House supervisor notified and physician notified." This note was written more than 5 hours and was the only description of the assessment, notification of family and physician and interventions that were found in pt. #1's MR.



Review of the facilities instruction for treatment of a patient after an unwitnessed fall is found in their Multidisciplinary Patient Care Manuel of Policies and Procedures. The policy is titled the "Falling Leaf Prevention Program". A review of the policy revealed the following:
1.c. A score of 45 or higher initiates High Risk Fall Prevention Interventions.
1.d. Patients are reassessed each shift, and another Morse Fall Scale and Falling Star Interventions are documented in Meditech under the nursing shift assessment.
1.e. The patient is reassessed after a fall.

2. Falling Star Program Initiation
2.a It the patient scores 25 or greater on the tool, the RN will identify interventions most likely to address specific risk factors and initiate the Falling Star Prevention Plan.
Place Falling Star Prevention Plan on White board
Place "Fall alert" armband on patient
Give patient yellow non-skid socks
Post fall sign on door
Review safety program, risk factors and interventions with family
Document Falling Star education on the Multidisciplinary Patient Education/Teaching record.
Document initiation of program in Meditech and patient Kardex.

3. Witnessed fall:
3.a. The nurse will examine patient and notify House Supervisor, Physician and family.
3.b. Documentation will be completed on all falls in the KBCore.
3.c. Falls are documented in Meditech and the Kardex.
3.d. The Morse fall scale will be completed.

4. Unwitnessed fall:
4.a. Do all of above under #3 and inform physician that it was un-witnessed and of potential head injury.
4.b. Complete a neurological assessment every 4 hours x 24 hours, every 8 hours for the next 48 hours and document on Post Fall Neuro Checks Screen.
4.c. Communicate any changes to the physician.
4.d. Provide Patient/Family Teaching Instruction (Attachment C) to the patient and/or family explaining the signs and symptoms of intracranial pressure after a fall.

5. Patient interventions: For patients Scoring 25-44 on Fall assessment, Consider the following:
5.a. Commode at bedside, urinal/bedpan within reach
5.b. Initiate Falling Star
5.c. Place patient at nursing station as needed for observation.
5.d. Move patient to room near the nurses station.
5.e. Pharmacist to evaluate medication regimen.
5.f. Night lights
5.g. Low beds or put mattress on floor.
5.h. Use gait belt
5.i. Utilize the mobility monitor when appropriate
5.j. Provide on-going assessments or patients identified high fall risk
5.k Determine patient's toileting habits and establish toileting schedule to meet those needs.
For patients scoring 45 or greater, Consider above, plus:
a. Individual supervision.
b. Chemical intervention.



Review of the documented physician's telephone order established a timeline of notification and new physician orders for pt. #1. Beginning at 6:00 p.m. Ativan 0.5 mg (milligrams) was ordered, to be given IV 1 time PRN anxiety. Review of the Medication Administration Record (MAR) identified RN #4 documented Ativan 0.5 mg was given IV at 8:54 p.m. The next physician's order was documented at 9:07 for Haldol 10 mg IM (Intramuscularly) one time for agitation. There was no documentation indicating the physician had been notified about pt. #1's fall or if the physician was only notified concerning pt. #1's agitation and combativeness. There was also no nursing documentation that the physician was made aware the Ativan had only been given at 8:54. The RN notified the physician at 9:07, requesting a stronger drug to control pt. #1's combative behavior fourteen minutes after giving the Ativan. The final physician's order was timed for 10:00 p.m. for a "Head CT in the a.m. d/t/ fall protocol". Pt's #1's unwitnessed fall occurred at 5:18. The nurse ' s documentation of the physician's telephone order, indicated the physician was notified of pt. #1's fall at 10:00 p.m. The nursing documentation does not indicate when the family was notified of pt. #1 fall.

Further MR review revealed, on 2/14/2015 a physician's telephone order was received to maintain pt #1 on telemetry. An interview with the Director of Nurses on 4/8/2015 in the conference room confirmed that routine telemetry orders were for vital signs (VS) to be taken every 4 hours. Pt #1's routine VS were established to be taken automatically every 4 hours beginning at 8:00 a.m. in the morning. Pt #1 was discovered on the floor of his room at 5:18 in the evening. VS were recorded before his fall at 4:00 p.m. No VS were recorded until the next scheduled time at 8:00 p.m. Although the nurse documented "Pt reported no injury and assessment revealed pt's neurological status to be WNL and no physical injuries assessed", there was no documentation of VS, or physical or neurological assessment immediately following pt. #1's un-witnessed fall.

The pre fall neurological assessment documented on 2/14/2014 at 0800 by the admitting nurse revealed, "pt. #1 was oriented to person place and time. He was oriented to his name he was awake alert his speech was appropriate he was able to follow commands, pupils equal round reactive to light and accommodation (PERRLA) and could understand concepts".

The post fall neurological assessment, revealed no vital signs (V/S) were immediately documented. Vital signs taken before pt. #1's fall were documented 2/14/2015 at 1600 (4:00 p.m.), before pt. #1 was found on the floor. Pt #1 fell at on 2/14/2015 at 17:18 (5:18 p.m.). The next documented vital signs were taken on 2/14/2015 at 20:00 (8:00 p.m.), more than 2 hours after his fall. Pt #1's Blood Pressure (B/P) was recorded as 156/93(high). The nurses assessment revealed the following: "Neurological WDP (within defined parameters) Except for, Orientation/Cognition, oriented to person, place, time, name, awake, alert, appropriate, follows commands, PERRLA". Then nurse #4 documented "Unable to comprehend, recent impaired (sic), speech Appropriate, unclear, mumbling, rambling excessive".


Pt #1's CT was completed the morning of 2/15/2015 at 10:49 a.m. with the following results. Findings: "On the previous CT, there was a chronic left frontotemporoparietal subdural hematoma. Now, within that chronic subdural fluid collection, there is a new dense, acute hematoma involving frontal, temporal, and parietal areas". As a result of these findings, patient #1 was immediately transferred to a facility that could provide a higher level of care.