HospitalInspections.org

Based on document review and interview, the facility failed to ensure nursing staff documented patient falls in the patient medical record for 2 of 7 patients with falls (Patients #5 and 9), failed to ensure nursing staff completed a post fall assessment for 3 of 7 patients with falls (Patients #1, 5 and 9), failed to ensure nursing staff documented a post fall risk assessment and updated fall prevention interventions for 1 of 7 patients with falls (Patient #9), failed to ensure nursing staff documented a complete nurse assessment within an hour of transfer to the Intensive Care Unit and a nurse reassessment every two hours or more often if patient condition changes for 1 of 10 medical records reviewed (Patient #1).

Findings include:

1. Facility policy titled "Fall Prevention Policy" last reviewed/revised 4/23/20 indicated the following: "I. PURPOSE: The Fall Prevention Policy purpose is to (1) establish a multi-disciplinary approach to fall prevention and implement fall prevention strategies to prevent falls...IV. PROCEDURE FALL RISK ASSESSMENT, SCREENING AND INTERVENTIONS...REQUIRED ACTION...6. Re-Assessments...Assess patient upon initial admission...Every shift assessment...Following a patient fall following a change in patient status/level of care...8. Documentation...General fall assessments documentation shall be completed in hospital-specific Electronic Medical Record (EMR) system..."

2. Facility policy titled "Post Fall Assessment Policy" last reviewed/revised on 11/30/19 indicated the following: "...I. POLICY...The fall prevention program is in place to keep patients safe and prevent falls. In the event that a patient does fall, guidelines have been developed to direct staff how to proceed with assessment, notification and management of care...IV. PROCEDURE...B...Post fall assessment to be completed in the EMR...2. Staff will stabilize the patient and assess for any injury...3. Document in the electronic medical record under the post fall assessment, leaving no items unmarked..."

3. Facility policy titled "Admission to Clinical Unit, Assessment and Reassessment, and Interdisciplinary Plan of Care Policy" last reviewed/revised 9/25/19 indicated the following: "...I. PURPOSE...C. To obtain information and make basic observations and general assessments regarding mental, emotional, and physical status of the patient...III. ASSESSMENT AND REASSESSMENT GUIDELINES: A. Assessment per shift: There must be evidence of a full assessment at the beginning of each shift, and more often as indicated by patient condition or nurse intervention. There must be evidence of a focused physical assessment completed by the RN [Registered Nurse] at least once each shift. B. Reassessment guidelines: A reassessment will be completed as often as indicated by hourly rounding, condition, level of care changes, or nursing interventions requiring reassessment...2. Critical Care and Intermediate patients in the Intensive Care Unit will be reassessed every two hours or more often if patient condition is changing..."

4. A review of the facility event log for the time period of 7/5/20 through 1/5/21 indicated the following:

a. Patient #1 had a fall on 10/12/20 at 12:23 p.m. with injuries.
b. Patient #5 had a fall on 7/25/20 at 2:50 a.m. with no injuries.
c. Patient #9 had a fall on 12/2/20 at 9:10 a.m. with no injuries.

5. Review of patient #1's medical record indicated the following:

(A) The patient was admitted on 10/9/20 at 12:17 p.m.

(B) Patient #1's medical record indicated the patient had a fall on 10/12/20 at 12:23 p.m. Progress notes by the Patient's providers indicated the patient had a laceration to his/her forehead and a nosebleed related to Patient #1's fall on 10/12/20 at 12:23 p.m. The MR lacked documentation of nursing treatment to head wound.

(C) The medical record lacked documentation of a complete nurse post fall assessment related to Patient #1's fall on 10/12/20 at 12:23 p.m. The medical record lacked documentation of a complete nurse assessment within an hour of admission to the Intensive Care Unit on 10/12/20 at 3:43 p.m. and lacked documentation of a nurse reassessment of Patient #1 prior to the patient transferring to Facility #2 on 10/12/20 at 7:50 p.m. The medical record lacked documentation of nursing treatment to Patient #1's head wound. Therefore, it could not be determined the status of any patient injuries from Patient #1's fall on 10/12/20 at 12:23 p.m. until their transfer to Facility #2 on 10/12/20 at 7:50 p.m. including treatments related to Patient #1's injuries.

6. Review of patient #5's medical record indicated the following:

(A) The patient was admitted on 7/23/20 at 5:34 a.m.

(B) The medical record lacked documentation of Patient #5's fall on 7/25/20 at 2:50 a.m. The medical record lacked documentation of a complete nurse post fall assessment related to Patient #5's fall on 7/25/20 at 2:50 a.m.

7. Review of patient #9's medical record indicated the following:

(A) The patient was admitted on 11/30/20 at 2:34 p.m.

(B) The medical record lacked documentation of Patient #9's fall on 12/2/20 at 9:10 a.m. The medical record lacked documentation of a complete nurse post fall assessment related to Patient #9's fall on 12/2/20 at 9:10 a.m.
The medical record lacked documentation of a post fall risk assessment and updated fall prevention interventions related to Patient #9's fall on 12/2/20 at 9:10 a.m.

8. During an interview with A9 (Medical/Surgical Team Coordinator) on 1/6/21 at 11:30 a.m., he/she verified that a fall risk assessment should be completed on patients upon admit, per shift and should reassess the fall risk assessment with any changes in patient status.

9. During an interview with A1 (Chief Nursing Officer) on 1/6/21 at 12:40 p.m., he/she verified that per policy critical care patients will be assessed within one hour of admit and every two hours. A1 verified that Patient #1 should've had a full head to toe assessment within an hour of admit to the Intensive Care Unit and prior to being transferred to Facility #2.

10. During an interview with A1 on 1/6/20 at 1:08 p.m., he/she verified that a complete head to toe assessment should be completed on a patient after a fall.

11. During an interview with A1 on 1/6/21 at 1:21 p.m., he/she verified that Patient #1's medical record lacked documentation from nursing related to any assessments/reassessments of injury/skin concerns after the patient's fall on 10/12/20 at 12:23 p.m.

12. During an interview with N1 (Registered Nurse/Charge Nurse) on 1/6/21 at 3:03 p.m., N1 verified that Patient #1 had a laceration that went up and down on the left side of his/her forehead and was not sure if the patient had a nose bleed or if the blood was from the patient's head laceration. N1 verified that they dressed Patient #1's forehead laceration with a 4x4 and wrapped kerlix around the patient's head to hold the dressing. N1 verified that N2 should have documented a complete post fall assessment on Patient #1.

13. During an interview with A9 on 1/6/21 at 3:58 p.m., A9 verified that the medical record for Patient #5 lacked documentation of a complete post fall assessment and fall documentation related to Patient #5's fall on 7/25/20 at 2:50 a.m. A9 also verified that a post fall assessment should be completed at time of patient fall or right after the fall, which would include a head to toe assessment and vital sign assessment. A9 verified that by reviewing just the medical record of Patient #5, it would not indicate that the patient had a fall on 7/25/20 at 2:50 a.m., due to lack of fall documentation.

14. During an interview with A9 on 1/6/21 at 4:02 p.m., A9 verified that there were no nursing notes and/or progress notes that indicated Patient #5 had a fall on 7/25/20 at 2:50 a.m.

15. During an interview with A9 on 1/6/21 at 5:40 p.m., A9 verified that the medical record for Patient #9 lacked documentation of a complete post fall assessment, post fall risk assessment and fall documentation by nursing staff for Patient #9's fall on 12/2/20 at 9:10 a.m.

16. During an interview with A3 (Quality Coordinator) and A9 on 1/6/21 at 6:00 p.m., they verified the medical record information for Patient's #1, 5 and 9.

17. During an interview with A9 on 1/6/21 at 6:10 p.m., he/she verified a lack of nursing documentation related to injuries and treatments provided related to Patient #1's fall on 10/12/20 at 12:23 p.m. and verified that the progress notes indicated the patient had a laceration to his/her forehead from the fall and a nose bleed.

Based on document review and interview, the facility failed to ensure nursing staff documented an initial plan for care, treatment and services within 24 hours of patient admission and updated the plan for care every shift and at patient discharge for 2 of 10 patient medical records reviewed (Patients #1 and 5).

Findings include:

1. Facility policy titled "Admission to Clinical Unit, Assessment and Reassessment, and Interdisciplinary Plan of Care Policy" last reviewed/revised 9/25/19 indicated the following: "...I. PURPOSE...D. Nursing care shall be planned by creating an initial plan for care, treatment, and services appropriate to the patient's specific assessed needs and then revising or maintaining the plan based on patient's response. The written plan of care is based on the patient's goals and the time frames, settings, and services required to meet those goals...IV. INTERDISCIPLINARY PLAN OF CARE (IPOC): A. All admitted patients will have a plan of care for treatment and services appropriate to the patient's needs identified by the assessments/reassessments. A collaborative, interdisciplinary approach to meeting the patient's needs and goals will help to coordinate care, treatment, services, and patient education in order to achieve optimal outcomes...C. POCs [Plan of Cares] are initiated within 24 hours of admission and updated every shift and at discharge..."

2. Review of patient #1's medical record indicated the following:

(A) The patient was admitted on 10/9/20 at 12:17 p.m. and transferred to Facility #2 (an acute care facility) on 10/12/20 at 7:50 p.m.

(B) Patient #1's medical record lacked documentation of an initial plan for care, treatment and services within 24 hours of patient admission and an update to the plan for care every shift and at patient discharge based on the patient's specific assessed needs and the patient's response.

3. Review of patient #5's medical record indicated the following:

(A) The patient was admitted on 7/23/20 at 5:34 a.m. and discharged on 7/27/20 at 1:34 p.m.

(B) Patient #5's medical record lacked documentation of an initial plan for care, treatment and services within 24 hours of patient admission and an update to the plan for care every shift and at patient discharge based on the patient's specific assessed needs and the patient's response.

4. During an interview with A1 (Chief Nursing Officer) and A9 (Medical/Surgical Team Coordinator) on 1/6/20 at 3:49 p.m., they verified the medical records for Patients #1 and 5 lacked documentation of a plan for care being initiated, updated every shift and at patient discharge.