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Based on review of facility documents, medical record review (MR) and staff interview (EMP), it was determined the facility failed to ensure a patient fall was analyzed, investigated or summarized to determine the cause of the patient's fall or to prevent the patient from falling again for one of one applicable medical records reviewed (MR1).

Findings include:

Review on August 13, 2012, of the facility's "Occurrence/Event Reporting" policy, last reviewed December 2009, revealed "I. Purpose: The purpose of this policy is to secure the facts concerning an occurrence/event; to promote and improve patient safety; to maintain the assets of the institution by risk identification and control. An occurrence/event is any event or happening which is not consistent with the routine operation of the facility or routine are of a particular patient. It may be an accident or a situation which may result in an injury. ..."

Review on August 13, 2012, revealed MR1 was admitted to the facility on July 6, 2012, with a history of falls. The Emergency Department staff assessed the patient's fall risk as high risk for falls. The admission history and assessment by the nursing staff assessed the patient as high risk for falls. Review of the facility's event reports revealed the patient fell on July 7, 2012. The patient was admitted to swing bed status on July 10, 2012. Review of the facility's Event Report for MR1 revealed this patient fell on July 11, 2012, which resulted in a fractured hip.

The facility was not able to provide documentation that MR1's falls on July 7 and July 11, 2012, were analyzed, investigated or summarized to determine the cause of this patient's fall or to prevent this patient from falling again.

Interview with EMP1 and EMP3 on August 13, 2012, at approximately 9:30 AM confirmed the facility was not able to provide documentation that MR1's falls were analyzed, investigated or summarized to determine the cause of this patient's fall or to prevent this patient from falling again.

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Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to determined the frequency fall risk patients were to have checks for safety completed and failed to document completion of the fall safety checks for four of 13 applicable medical records reviewed (MR1, MR3, MR4 and MR5).

Findings include:

Review on August 13, 2012, of the facility's "Fall Prevention Care Plan," last revised April 2011, revealed "... Expected Outcome ... Patient will remain safe and injury free during hospital stay. ... Interventions Perform fall assessment on admission and during hospitalization as needed for fall risk. ... Check patient Q [every] Hrs [Hours] ..."

Review on August 13, 2012, of the facility's "Fall Prevention Protocol," last reviewed April 2011, revealed "... Key Points ... Frequency q [every] 1 -2 hrs [hours]. individualized [sic] per patient care plan. ..."

1. Review of MR1's Fall Preventions Care Plan on August 13, 2012, revealed an area for the nursing staff to determine the frequency MR1 should be checked by nursing staff for fall risk safety. The Fall Preventions Care Plan also contained an area for nursing staff to document the results of the safety checks in the medical record.

Further review of MR1's Fall Prevention Care Plan revealed no documentation indicating the frequency the nursing staff was to check this patient for fall risk safety. There was no documentation in MR1 of the results of the safety checks in the medical record.

Interview with EMP3 on August 13, 2012, confirmed MR1's Fall Prevention Care Plan did not indicate the frequency nursing staff was to check MR1 for fall risk safety and the documentation of the results of the safety checks in the medical record. Further interview with EMP3 confirmed the nursing staff should have checked MR1 hourly for fall risk safety and documented the results in MR1's medical record.

2. Review on August 13, 2012, of MR3, MR4 and MR5's Fall Preventions Care Plans revealed no documentation indicating the frequency nursing staff was to check these patients for fall risk safety and no documentation of the results of the safety checks in these patient's medical records.

Interview with EMP3 on August 13, 2012, confirmed MR3, MR4 and MR5's Fall Prevention Care Plan did not indicate the frequency nursing staff was to check these patients for fall risk safety and documentation of the results of the safety checks in these patients' medical records.
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Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to follow their established policy to daily reassess patients identified as at risk for falls for nine of 13 applicable medical records reviewed (MR1, MR3, MR4, MR5, MR6, MR7, MR9, MR10 and MR11).

Findings include:

Review on August 2, 2012, of the facility's "Fall Prevention Care Plan," last revised April 2011, revealed "... Expected Outcome Patient will remain safe and injury free during hospital stay. ... Reassess fall risk q [every] shift/day/condition change. ..."

1. Review on August 2, 2012, of MR1 revealed the patient was admitted on July 6, 2012. Nursing staff determined the patient was at high risk for falls. Review of MR1's Fall Assessment Tool revealed the facility completed a fall assessment on July 9 and 12, 2012.

Interview with EMP1 and EMP2 on August 2, 2012, at approximately 3:00 PM confirmed the nursing staff did not reassess MR1's fall risk each day, as required by facility policy.

2. Review on August 13, 2012, of MR3, MR4, MR5, MR6, MR7, MR9, MR10 and MR11 revealed the nursing staff determined these patients were at high risk for falls. Further review of MR3, MR4, MR5, MR6, MR7, MR9, MR10 and MR11's Fall Assessment Tool revealed no documentation the patients were reassessed daily during their hospitalization, as required by hospital policy.

Interview with EMP1 and EMP3 on August 13, 2012, at approximately 9:15 AM confirmed there was no documentation in MR3, MR4, MR5, MR6, MR7, MR9, MR10 and MR11 that the patients were reassessed daily for fall risk during their hospitalization, as required by hospital policy.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to implement a Fall Prevention Care Plan on patients identified as high risk for falls for three of 13 medical records reviewed (MR1, MR4 and MR10).

Findings include:

Review on August 2, 2012, of the facility's "Patient Care Plan and Nursing Diagnosis Protocol" policy, last reviewed September 2009, revealed "Expected Outcomes: 1. To develop a standardized approach in medical and nursing care of patients commonly found on specific nursing units. ... Responsibility: After the initial assessment is accomplished for the inpatient, the RN [Registered Nurse] is responsible for initiating the appropriate patient Care Plan for the patient. The RN individualizes it to meet the patient's nursing needs and places it on the bedside chart. Standard Instructions: ..."

Review on August 2, 2012, of the facility's "Fall Prevention Care Plan," last revised April 2011, revealed "... Expected Outcome ... Patient will remain safe and injury free during hospital stay. ... Interventions Perform fall assessment on admission and during hospitalization as needed for fall risk. Initiate fall protocol if identified as a moderate or high risk using the Fall Assessment Score..."

Review on August 13, 2012, of the facility's "Fall Prevention Protocol," last reviewed July 2011, revealed "Expected outcomes: To identify high risk patients prone to falls, define measures to prevent falls and delineate action post falls. Standard 1. Identify patients in high risk categories on admission interview using the Fall Assessment tool which will be included with care plan. If conditions change during the hospitalization or a fall occurs, reassess the patient using the Fall Risk assessment and intervene for the following scores: a. Low fall risk 0 -5 points. b. If moderate or high risk with score greater than 5, implement high risk fall preventions, initiate care plan and educated patient. 2. Initiate a fall preventions Care Plan as indicated by Fall Assessment Tool, update and reevaluate at least daily. ... If a high risk: ... c. Check patient frequently (Frequency q 1 - 2 hrs. or 2 - 3 hrs. individualized per patient care plan) d. Use contents of "alternative box" to occupy patient e. Request a family member to stay at the bedside. ... "

Review on August 2, 2012, of the facility's "Admission History and Assessment" form, no review date revealed "... Fall/Functional Screen ... Total 0-24: Basic Nursing Care 25 - 45: Implement Standard Fall Careplan [sic] 45 and above: High Risk Intervention, Green Band, Careplan [sic] and Physical therapy Consult ..."

1. Review on August 2, 2012, revealed the facility admitted MR1 on July 6, 2012, with a history of falls. Emergency Department (ED) staff assessed MR1's fall risk as 8, indicating MR1 as high risk for falls.

Review on August 2, 2012, of MR1's Admission History and Assessment revealed nursing staff assessed MR1's fall risk as 110 on admission, requiring a High Risk Intervention per facility policy.

Review on August 2, 2012, of the facility's Event Reports for MR1 revealed the patient fell on July 7, 2012.

Further review of MR1 revealed the Fall Prevention Care Plan for the patient was implemented on July 9, 2012.

Interview with EMP1 and EMP2 on August 2, 2012, confirmed MR1 was admitted to the facility on July 6, 2012; the patient fell on July 7, 2012, and a Fall Prevention Care Plan was implemented on July 9, 2012.

2. Review on August 13, 2012, revealed MR4 was admitted on April 17, 2012. Review of MR4's Admission History and Assessment revealed nursing staff assessed the patient's fall risk as 55 on admission, requiring a High Risk Intervention per facility policy. Further review of MR4 revealed a Fall Prevention Care Plan for the patient was implemented on April 18, 2012.

Interview with EMP1 and EMP3 on August 13, 2012, confirmed MR4 was admitted to the facility on April 17, 2012; the facility assessed MR4's fall risk as 55; and the Fall Prevention Care Plan for this patient was implemented on April 18, 2012.

3. Review on August 13, 2012, revealed MR10 was admitted on June 9, 2012. Review of MR10's Admission History and Assessment revealed nursing staff assessed the patient's fall risk as 40 on admission, requiring a High Risk Intervention per facility policy. Further review of MR10 revealed a Fall Prevention Care Plan was not implemented for this patient.

Interview with EMP1 and EMP3 on August 13, 2012, confirmed MR10 was admitted to the facility on June 9, 2012; the facility assessed MR10's fall risk as 40; and the facility did not implement a Fall Prevention Care Plan for this patient.