HospitalInspections.org

Based on interview, record review, and policy review the Critical Access Hospital (CAH) failed to ensure the nursing care plan was kept current, updated or revised for one of 10 Patients (Patient 7) reviewed for falls. This deficient practice has the potential to affect all patients in the facility.

Findings Include:

Review of the facility policy, "Fall Prevention Plan" effective 04/15/19 stated, "Purpose: Fall prevention is an important part of patient plan of care within all inpatient and outpatient areas at Edwards County Medical Center (ECMC). Procedure ...c. High Risk Interventions (>51):v. Consider moving patient closer to the nurse station or to a room with visual access ...vii. Consider making patient 1:1 ..."

Review of the facility policy, "Fall Prevention, Three Level Precaution, Documentation" revised 04/19 stated, "Purpose: To identify patients at risk for falls and to provide prevention and three level fall precautions to prevent injury from falls. Policy: It is the policy of the unit to provide ongoing assessment for fall risks and to implement interventions to prevent falls from occurring ...10. Prevention and Three Level Precaution Fall Risk ...c. Level 3 (High Risk Patients-Score>10) (Red Leaf) ...i. Have patient visually monitored at all times. ii. Physical assistance with all changes in position. iii. Do not put patient to bed if not tired."

Review of the medical record showed Patient 7 was admitted to the hospital on 03/18/19. The psychiatric evaluation, completed on 03/18/19 documented diagnoses including adjustment disorder with mixed anxiety depressed mood, Schizoaffective Disorder, Bipolar type; probable major neurocognitive disorder due to Alzheimer's Disease with behavioral disturbance, major depressive disorder, recurrent, with psychotic features, generalized anxiety disorder, insomnia disorder. The behavioral health RN "Admission Assessment" completed on 03/18/19, documented the "Morse Fall Scale" indicating Patient 7 was a high risk for falls based on a score of 115 (score over 51 indicates a high risk for falls).

The "Master Treatment Plan Problem Sheet", completed by nursing on 03/18/19 documented a Fall Risk due to new medications, unfamiliar with the unit and altered mental status. The related goal was the patient would remain free from injury or falls during the hospital stay. The clinical interventions listed for Fall Risk were: "1. Assist patient to walk with help. 2. Advise patient to call nurses for help as needed. 3. Bed alarm on bed. 4. Assist with ADL's (Activities of Daily Living) as needed. 5. Fifteen minute checks. 1/1 as needed. 6. Alarm in chair. 7. Bed in low position. 8. Matt at side of bed. 8. Non-skid foot wear. 9. PT/OT(Physical Therapy/Occupational Therapy) as needed. 10. Provide diversional activities".

The "Individual Patient Note" dated 04/02/19 at 6:17 PM completed by the RN documented the plan of care as follows: "Problem #1 Altered Mental Status: Oriented to self only. Continues to be confused. Problem #2: Anxiety: Patient continues to be anxious at times. He has not struck out at staff thus far this shift. Problem #3: At risk for Falls: Continues fall precautions with 15 minute checks. No falls noted thus far this shift. Problem #4 Self Care Deficit: Patient continues to need assistance with Activities of Daily Living (ADL's) Problem #5: Impaired Physical Mobility: Continues to need staff's assistance ..."

The "Individual Patient Note" dated 04/04/19 at 12:10 AM documented Patient 7's bed alarm sounded, and the patient was found sitting on the side of the bed. Staff noted that Patient 7 was incontinent of urine and requested that Patient 7 continue to sit on the side of bed while staff gathered a change of clothing and bedding that was outside the room. While staff was getting the clothes and bedding, Patient 7 (who had been left alone in the room) fell and landed on his left side sustaining lacerations to the left cheek and eyebrow. The RN assessment completed did not identify other injuries and Patient 7 was assisted to the chair by two staff members. The Physician Assistant (PA) was notified and application of an ice pack was ordered, and neurology checks were completed.

"The Individual Patient Note" dated 04/09/19 at 1:38 AM completed by the RN documented the care plan as follows: "Problem #1 Altered mental status: Patient is alert to self. Problem #2 Anxiety: No anxiety this shift so far. Problem #3 Fall Risk: Fall Precautions initiated on admission and continue through the stay with every 15 minute checks. Patient walks with 2 staff assistance. Problem #4 and #5 Self-care deficit and impaired mobility: Patient is working with Physical Therapy (PT). Patient is encouraged to do as much of ADL's as he can for himself ..."

The "Individual Patient Note" dated 04/09/19 at 11:10 PM documented Patient 7's bed alarm sounded, staff entered the room and the patient was up and out of bed staggering/stumbling to the door. Staff attempted to intercede and assist but Patient 7 moved away and began to fall backward. When falling, Patient 7 turned, hit the mattress and landed on the floor sustaining a skin tear on the right hand. The RN assessment was completed with no other injuries noted. Patient was assisted to the chair by two staff members.

Review of Patient 7's medical record failed to reflect documentation staff reassessed and implemented interventions in the plan of care after the fall on 04/04/19 and 04/09/19.

Interview on 06/03/19 at 3:45 PM, Staff A, Program Director (PD) said that after Patient 7 fell the patient's care plan was not altered [updated with new interventions] for fall prevention because the patient already was receiving the highest level of care in relation to falls. Staff A, PD said the patient was a high risk and the "Red Leaf" (use of colored leaf to alert staff of high risk for falls) program was implemented. Staff A, PD explained that a fall assessment is completed on each patient every shift. Staff A, PD explained that on the night shift when Patient 7's falls occurred staffing included one RN and 2 nurse aides. During the night shift the nurse aides sit at opposite ends of the hallway to monitor and respond to patient's needs. Staff A, PD stated that all staff receive training/education regarding fall prevention throughout the year. Staff A, PD stated that one to one monitoring and moving patients closer to the nurse's station are interventions that can be used, but were not used after Patient 7's falls on 04/04/19 and 04/09/19. Staff A, PD did not know why changes were not made after the falls occurred.