HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure fall risk prevention interventions were in place for 2 (P-1, P-2) of 4 patients reviewed, and that post fall interventions per facility policy were carried out for 1 (P-1) of 4 patients reviewed with high-risk fall precautions resulting in the increased likelihood of negative consequences for the patients. Findings include:

On 5/16/2025, P-1 experienced an unwitnessed fall in the restroom prior to having a stress test performed. P-1 was 87 years-old, legally blind, and was considered a patient at high risk for falls.

On 7/29/2025 at 0830, Nuclear Medicine Technologist Staff S was interviewed with Union Representative Staff BB about their role in caring for P-1. Staff S revealed P-1's stretcher was near the restroom in the Nuclear Medicine department and P-1 "wanted to use restroom" and they "helped P-1 into restroom and stepped outside restroom door." Staff S revealed they normally ask the patient if they required help but didn't remember if that "was told." Staff S proceeded to step outside restroom and stood at the door and at some point heard P-1 fall. Nuclear Medicine Technologist Staff L and Staff S went into the restroom and observed P-1 "in front of sink". Staff S revealed that after P-1 fell, their "manager instructed" Staff S should have stayed "in the restroom" and Staff S revealed that they were "not aware of policy."

On 7/29/2025 at 0915, Cardiac Nurse Staff O was queried about their involvement in treating P-1. Staff O revealed after P-1 fell prior to their stress test, Staff O performed a mini-assessment of P-1 and noticed P-1 did not have a fall bracelet or yellow socks on. Staff O revealed they had to go to the Emergency Department to obtain and apply the bracelet and socks to P-1 and this information was "communicated" to the P-1's inpatient nurse.

According to a review of P-1's medical record on 7/28/2025 at 1230, there was no post-fall order set and no post fall care plan initiated for P-1 by the nurse.


On 7/28/2025 at 1210 during survey tour, current patient P-2 was having a stress test completed and Nuclear Medicine Technologist Staff L was queried to describe the communication process when an inpatient was transported to Radiology for a procedure, they brought forward a hand off form that listed patient information including whether the patient was a fall risk. P-2's hand off communication form was reviewed and revealed the section for communicating Fall Risk status was not checked.

On 7/28/2025 at 1300, P-2's medical record was reviewed with Clinical Informatics Staff N and P-2 was identified as a high risk for falls.

On 7/29/2025 at 1315, Director of Nursing Staff Y was queried and reviewed a copy of the P-2's hand-off communication form and confirmed the section of Falls Risk should have been completed by the inpatient nurse. Staff Y was also asked if they expected staff to follow policies and procedures and they revealed "Absolutely."

According to the facility's policy "Adult Fall Prevention," dated 7/10/2025, for "Risk Directed Care," "Caregiver to remain within arm's reach of patient during toileting, 1. Includes bathroom and bedside toileting, 2. Safety is the priority." The policy also revealed "Place fall risk identifiers such as armband/coordinating nonskid socks on the patient according to organization processes."

The policy also revealed that for "Post Fall Management Assessment and Documentation," "Nurses initiate the post fall order set in the EHR (electronic health record) and implement a post fall care plan with the patient/family/caregiver."

According to the facility's policy, "Handoff and Communication during Patient Transportation," dated 8/23/2024, "This policy provides safety guidelines for handoff and communications between staff during the transportation of patients within the (facility). At the time of transport, the Healthcare Provider (HCP) caring for the patient: completes the "Patient Handoff Worksheet," reviews it with the Transporter and the worksheet remains with the patient."

Based on interview and record review, the facility failed to follow national standards in evaluating patients after placing a patient in four-point locking restraints for 1 (P-11) of 3 patients reviewed for restraint and seclusion monitoring resulting in the loss of patient rights for the patient. Findings include:

P-11 had four-point locking restraints ordered on 2/24/2025 at 1907 and discontinued on 2/24/2025 at 1938 and there was no documentation that the face-to-face medical evaluation was performed after initiation of the restraints. Clinical Informatics Nurse Staff N confirmed the findings at the time of discovery.

According to the facility's policy, "Restraint," dated 5/8/2025, for "Physician Responsibilities," "Perform an in-person evaluation of the patient in restraint within 1 hour after the initiation of restraint by a physician to evaluate at a minimum: This evaluation will include the patient's:

a. immediate situation
b. reaction to the intervention
c. medical and behavioral condition AND the need to continue or discontinue the restraint
d. the patient's physical and psychological status;
e. the patient's behavior that warranted the intervention, the intervention used;
f. alternative or less restrictive measure attempted (if applicable) and the appropriateness of the intervention measures;
g. the patients' response to the intervention used, including rational for continued use;
h. any complications resulting from, the intervention."

The policy also revealed that "A patient may be restrained prior to examination pursuant to an authorization. A qualified nurse may initiate a patient restraint to address violent behavior prior to a physician's evaluation, A physician must personally examine the patient in person within 1 hour of the initiation of restraints, even if the restraints were removed within that first hour."