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Based on hospital policy reviews, medical record reviews, daily staffing assignment sheet reviews, fall log review, personnel file reviews, memorandum reviews, and staff interviews, the hospital's nursing staff failed to follow hospital policy to notify patients' families of falls for 3 of 6 records reviewed with falls (#2, 13 and 18); to complete skin assessments for 2 of 6 patients (#2 and 18) and assess patients for fall risk for 1 of 20 patients (#15).
The findings include:

Review of the policy "Documentation" on 2/13/13 revealed "1. Nursing assessments-BH (behavioral health) and MS(head to toe physical) for Med/Psych, BH for Women's and Gero units, q (every)12 hours. 2. Fall assessment every 12 hours."

Review of the policy "Fall Prevention" revealed "Patients are assessed upon admission and each shift for fall risk, and measures are taken to minimize the risk of falling"...."When a Patients Falls:....3. Document factual and objective description of the patient's fall and intervention in the Power-Chart in Shift Assessment band/ Falls Documentation section. 4. Notify family or responsible party and document in Power-Chart in the falls documentation section under Shift Assessment band in Falls Documentation section."

1A. Patient #2 was admitted on 5/11/12 at 5:00pm to the Gero/Psych Unit with diagnoses of Dementia with delusion and behavioral disturbance, long term history strongly suggests underlying bipolar disorder, psychosis and long-term history also suggests traumatic cluster personality disorder." Medical record review on 2/13 & 2/14/13 revealed the nurses did not evaluate the patient's skin according to facility procedure.

Review of Patient #2's admission assessment dated 5/11/12 revealed "Pt present in a w/c, oriented to self only....Pt did take afternoon meds. Pt ambulated with PT 2 assist. No acute distress noted. Review of nursing documentation dated 5/12/13 at 0:405 revealed the patient was "cooperative with skin assessment". The nurse documented the patient had bruising of the right and left hands. There was no documention the patient's skin was assessed again until 5/23/12 (11 days later) when the patient had a fall. Nurse #1 documented "Pt found on the floor in her room @ 1545, pt assisted to bed and assessed. Pt noted to have small amount of blood on L upper lip. no source of blood found. MD notified of fall. V/S (vital signs) WNL (within normal limits)." Nurse #1 documented on "5/24/12 at 16:07. Pt up in w/c sitting in the hall most of this shift. Pt cont to yell most of the day, Pt has light blue bruising noted around her chin. Pt also has a small abrasion on L (left) side forehead." The patient was discharged on 5/31/12 and the nurse documented on this date the patient was "alert, confused calling out frequently, oob ambulated with therapy. report called to ____nursing home. paper work with driver, discharged via w/c at 1100". There was no evidence in the medical record the bruising of the face and abrasion of the head were reassessed after 5/24/12. Review of the plan of care revealed the plan for skin integrity was not reviewed or revised from 5/16/12 to 5/31/12.

Interview with RN #1 and RN #2 on 2/13/13 at 12:05 pm revealed skin assessments are to be documented on admission and at discharge. RN #2 stated skin assessments should also be documented every shift, which should include bruising or skin breakdown.

Interview with the Director of Behavior Health on 2/14/13 on 10:30 am revealed the nurses are to document a complete nursing assessment, which includes a skin assessment on the day of admission and discharge. Interview with the Director of Behavior Health confirmed the nursing assessments were not complete.

1B. Review of medical record #2 on 2/14/13 revealed the patient had a fall on 5/23/12. Review of the nursing notes revealed:
5/23/12 at 16:08 "Pt (#2) found on the floor in her room @ 1545, pt assisted to her bed and assessed. Pt noted to have small amount of blood on L upper lip. no source of blood found. MD notified of fall. V/S (vital signs) WNL (within normal limits)."
5/24/12 at 16:07. Pt up in w/c sitting in the hall most of this shift. Pt cont to yell most of the day, Pt has light blue bruising noted around her chin. Pt also has a small abrasion on L side forehead. Pt assisted with adl's(activities of daily living) as needed. Monitored q (every 15 for safety, meds given per MD orders. Will continue above interventions." Review of the fall log and medical record on 2/13/13 revealed no evidence the family was notified of the patient's fall.

Interview with RN #1 on 2/13/12 at 1:30 pm confirmed she was on duty on 5/23/12 when patient #2 had a fall. RN #1 stated she did not recall if the family was notified. She confirmed that she did not complete the falls documentation section in the medical record.

Interview with RN #2 at 12:05 pm on 2/13/13 (on duty in Gero/Psych Unit) )revealed the nurses are to documented in the fall log when a fall occurs. She stated she was not aware the nurses were to complete the falls documentation section in the medical record.

Interview with the Nursing Supervisor on 2/14/13 at 9:05 revealed any fall should be recorded on the falls log and in the medical record under the falls documentation section. The Nursing Supervisor confirmed there was no evidence patient #2's family was notified of the fall or evidence the nurses had completed the falls documentation section in the medical record. .

2. Patient #15 was a 73 old was admitted to the Gero/Psych Unit on 2/12/13 at 1400 pm with a diagnosis of Dementia. Record review revealed no evidence a fall assessment was completed within 12 hours of admission.

Review of the medical record on 2/12/13 revealed there was no fall risk assessment done until 2/13/12 at 9:00 am (19 hours).

Interview with the Administrative Staff on 2/13/13 at 3:45 pm confirmed the nurses failed to follow policy to assess this patient for falls every 12 hours.


3. Patient #13 was admitted to the Medical Surgical Unit on 11/12/12 with diagnoses of Cellulitis, Osteomylitis and Non Healing Diabetic Wound. Review of the medical record on 2/13/13 revealed
a the patient had a fall on 11/18/12. The nurse documented "Pt fell in room with PT during therapy, bump head on wall, no pain, neuro checks, stable. Dr.____notified no new orders at this time. Will continue to monitor and provide support." There was no evidence the patient's family was notified of the fall.

Interview with administrative staff on 2/13/12 at 3:05 pm confirmed there was no documentation the family was notified of this patient's fall.


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2. Patient # 18 was admitted 12/18/12 with diagnoses of Pneumonia, First Degree Heart Block, Mental Retardation and Hypertension. Review of medical record for admission 12/18/12 - 12/23/12 revealed nursing documentation dated 12/20/12 at 20:25 which stated, "Nurse heard patient fall while trying to go to the BR (bathroom) unattended. No injury noted. Dr. (name of physician) notified. Orders received and initiated." Review of "Shift Assess" nursing documentation revealed "Integumentary Assess" documentation for 12/20/12 at 0:700 which indicated the skin was "intact." Documentation on 12/20/12 at 17:00 indicated skin "intact." Documentation on 12/21/12 at 0:900 indicated "skin intact." No further skin assessment was documented until 12/23/12 at 0:800 which stated, "Bruise noted on (L) hip and upper back." Continued review of the medical record revealed a roll belt restraint was initiated on 12/20/12 at 20:25 after the documented fall. Further review of the medical record revealed no evidence the patient's family was notified of the fall and subsequent use of restraints.

Interview with the unit supervisor on 2/14/13 at 11:00 AM confirmed the nursing staff had not followed hospital policy by failing to notify a family member of the patient's fall.

NC 00081334