HospitalInspections.org

Based on interview, record review and a review of facility documentation, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care of a patient with respect to her risk for falls and the application of compression stockings in accordance with policy for 1 of 5 sampled patients (#1).

Findings:

Patient #1's History and Physical of 4/13/19 read, "Patient....with PMHx (past medical history) of Atrial Fibrillation w (with)/Pacemaker in place....presents for near syncopal event, described as dizziness wo LOC [without loss of consciousness] and weakness that began that morning at 9 AM....Patient states she was recently discharged from [another hospital] after having a fall....resulting in a left distal clavicular fracture."

A nurse's note of 4/14/19 at 4:23 PM read, "While the patient was doing orthostatic vitals she went from sitting to standing, her oxygen level dropped to 87 but when she took some cleansing breathes she came right up to 97%." This entry indicated that the patient would be at a risk for falling. A fall risk assessment of 4/14/19 at 7:51 PM indicated that the patient was at a moderate risk for falls. A fall risk assessment completed on 4/16/19 at 12:35 PM indicated that the patient was at a high risk for falls. There were no more fall risk assessments until 4/16/19.

Physician orders of 4/15/19 at 10:38 AM read, "Compression Stocking(s)....thigh high, gradated."

A nurse's note for fall documentation of 4/15/19 at 2:15 PM read, "Fall date and time: 4/15/19 2:15 PM. ...Activity prior to fall: standing. ...Fall description/comment: Helping patient put ted [anti-embolic hose] on, patient lost balance and fell." This statement indicates that the nurse was attempting to place compression stockings on the patient while the patient was standing. On 6/25/19 at 12:49 PM, the Risk Manager confirmed that this entry reflected that the patient fell from a standing position while there was an attempt to place compression stockings on the patient.

On 6/25/19 at 12:35 PM, the Risk Manager stated that although the facility did not have a written policy which outlined steps to take in putting compression stockings on a patient, she stated that they follow A.G. Perry, P.A. Potter and W.R. Ostendorf, 2018, "Clinical nursing skills & techniques" (9th ed.). Under the heading of "Antiembolic Stockings and Sequential Compression Devices" were the following instructions: "Assist the patient in moving to the supine position. Elevate the head of the bed to a comfortable level....Apply antiembolic stockings." During the interview, she also stated that the facility has an expectation the compression stockings not be placed on patients while they are standing.

On 6/25/19 at 1:35 PM, as to whether the facility was aware of the lack of fall assessments, the Risk Manager stated they were not aware of the omissions.

The hospital policy "Fall Prevention - Assessment and Interventions" revealed the following: "All adult patients will be assessed for falls risk using the Morse Falls Scale (MFS) or Falls Risk Screening Tool. Assessments will be performed upon admission or service, once per shift or service, and whenever there is a change in the level of care or patient's status or condition."

On 6/25/19 at approximately 3:20 PM, the Risk Manager she confirmed the findings.