HospitalInspections.org

Based on record review and staff interview, the facility failed to ensure clear expectations for safety were established. This had to potential to affect all patients assessed for high fall risk. The facility census was 218.

Findings include:

Review of the undated Clinical Decision Unit Meeting notes revealed staff education for high fall risk. The education revealed all high fall risk patients would have a bed alarm, a yellow magnet sign on door, a "Call Don't Fall" sign in room, discussion of fall risk and interventions with patient, yellow socks, yellow wrist band, one to one if needed, and low bed with floor mat if needed. Review of the policy and procedure for Falls Prevention Program, effective 11/05/2020, revealed the policy did not reflect the new high fall risk interventions.

Interview with Staff #1 on 11/18/2020 at 10:28 AM confirmed the above findings.