HospitalInspections.org

Based on policy review, medical record review, and interview, the facility failed to ensure the patient's legal representative was notified with a change in condition for 2 of 3 sampled patients (Patient #1 and #12) reviewed for falls.

The findings included:

Review of the policy titled "Patient Fall Prevention Program," dated 12/4/2023, revealed "...PURPOSE...Establish post-fall huddle and Serious Safety Event (SSE) reporting guidelines ...Notification of the fall...At a minimum, the Attending Physician, Nursing Leader, and patient legal representative will be notified as soon as possible..."

Review of the medical record revealed Patient #1 was admitted on 10/27/2022 with diagnoses that included Delirium, Pneumonia, Diabetes, Hypertension, Atrial Fibrillation, Kidney Transplant, and Chronic Kidney Disease.

Review of the "Nurse Note," dated 11/9/2022, revealed "...PT [patient] ATTEMPTED TO GO TO THE BATHROOM UNASSISTED, BATHROOM CALL LIGHT GOING OFF. TECH [technician] WENT TO ROOM AND HEARD PT YELLING FOR HELP. TECH GOT HELP AND GOT PATIENT TO FEET AND BACK TO BED. GRIP SOCKS ON FEET AT TIME OF FALL. WHEN ASKED WHAT HAD HAPPEN, PATIENT STATED HE NEEDED TO USE THE BATHROOM AND LOST BALANCE AND FELL BACKWARD..."

Review of the "Progress Note," dated 11/11/2022, revealed "...Called niece, [Named family Member #2], and updated her on his care, She was aware of the fall via Air Ambulance..."

The facility failed to complete a Post-Fall debrief and an incident report for Patient #1. The facility failed to list Patient #1 on the fall log dated November 2022.

During an interview on 3/18/2025 at 10:36 AM, the Vice President Quality/Risk was asked if there was an incident report completed for Patient #1's fall on 11/9/2022. The Vice President Quality/Risk confirmed there was no incident report or post fall debriefing tool completed for the fall on 11/9/2022. The Vice President Quality/Risk was asked should the legal representative be notified after each fall. The Vice President Quality/Risk confirmed the family should be notified after each fall.

Review of the medical record revealed Patient #12 was admitted on 2/28/2023 with diagnoses of General Weakness, Fracture of Left Humerus, Acute Renal Failure and Hypotension.

Review of the "Post-Fall Debrief Tool," dated 3/1/2023, revealed "...Pt [patient] tech [technician] told this nurse pt was in bathroom & [and] would use call light when done in restroom. A few minutes later...[Name Tech] came to me at nurse desk & reported pt fell, used call light but lost his balance..."

During an interview on 3/1/2025 at 2:33 PM, the Vice President Quality/Risk when reviewing Patient #12's incident report was asked if the legal representative was notified during the fall incident on 3/1/2023. The Vice President Quality/Risk confirmed the legal representative was not notified after the fall that occurred on 3/1/2022.

During an interview on 3/18/2025 at 3:45 PM, Registered Nurse (RN) #1 was asked what was the procedure for when a patient fell. RN #1 stated, "...We inform the doctor...write a report [post fall debrief]...check the patients vital signs...have the witness help get the patient up to the chair...make sure the patient is okay...inform the nursing supervisor...complete the post fall debrief...notify the family..." RN #1 was asked where nursing documented that the family was notified. RN #1 confirmed she would document the notification of the family in the fall interventions and in her notes.

The facility failed to notify the patient's legal representative after each fall.