HospitalInspections.org

Based on document review, observation and staff interview, it was determined in 6 of 11 (Pts. # 2,3,4,5,6, and 7) patients on the 7th floor who scored higher than a 4 on the falls risk assessment, the Hospital failed to ensure all the required precautions were implemented.

Findings include:

1. The Hospital policy and procedure titled, "Fall Prevention Program" (With an effective date of July 17, 2013) was reviewed. It indicated under, "Fall Risk Assessment...2. The patient's risk assessment is performed and scored using the Hendrich II Fall Risk Model: a) On admission to the hospital b) Twice in a calendar day c) Upon transfer from another unit, d) After a fall". And under , "NOTE:...5. Add all risk points to determine a total fall risk score. a. A final fall risk score of less than 5 points requires implementation of basic fall prevention interventions, i.e., "Fall Prevention Interventions.....2. The following fall prevention interventions will be implemented for patients identified as being at high risk for falling with a total fall risk score of 5 or above on the Hendrich II Fall Risk Model...a) Identify/communicate patient as being at High risk for falling with: Color coded fall risk wrist band, Color coded fall risk identifier outside patient's room..."

2. During a tour of the 7th floor, conducted on 11/7/14 at 10:45 AM, a roster of all the current patients that scored a 5 or higher on the Hendrich Falls Risk Model was obtained. Each of the patients rooms were visited and the following observations were made:

a) Pt #2 in room 712-AA scored a 5 on 11/3/14 and a 6 on 11/6/14. There was no wrist band on the patient.

b) Pt #3 in room 718-AA scored a 6 on admission (11/4/14/). There was no wrist band or markers on the door.

c) Pt #4 in room 730-AA scored a 9 on 11/5/14. There was no wrist band on the patient.

d) Pt #5 in room 734-AA scored a 7 on 11/2/14 and a 9 on 11/6/14. There was no wrist band on the patient.

e) Pt #6 in room 742-AA scored a 6 on 11/5/14 and a 6 on 11/6/14. There was no wrist band on the patient.

f) Pt #7 in room 744-AA scored a 6 on 11/5/14 and a 6 on 11/6/14. There was no wrist band on the patient.

3. During an interview with the Charge Nurse (E-3), conducted on 11/7/14 at 11:30 PM, it was stated that all of the patients that scored a 5 or higher should have had both the wrist band and the door markers in place.