HospitalInspections.org

Based on observation and record review, the registered nurse failed to follow policies and procedures for 1 current patient (#1) and 3 discharged patients ( #2, #3 and #4) who experienced falls resulting in neglect of patients at high risk for falls of 4 total records reviewd. Findings include:
Policies:
" Falls: Risk Assessment, Intervention, and Post-Fall Follow-Up-Adult Inpatient", dated 2/24/12, states:
1. Definition: A fall is defined as an unplanned descent to the floor. Included in the definition are patients found lying on the floor unable to account for their situation.
2. The Morse Fall Scale is completed by a RN.
3. SBAR/Hand off Report includes the patient ' s fall risk status ...falls that have occurred during this admission ...
4. Post-fall follow-up assessment: When a fall occurs the RN will complete an assessment.
" Appendix B, Post-Fall Follow-up, " states:
8. Complete a Safety Call-Out for all falls and complete a post-Fall Huddle if unwitnessed.
" Safety Call-Out" (Incident Reporting), dated 6/30/11 states:
5.1 " The staff member who is closest to, or witnesses the event shall be responsible to report the event to the best of his/her abilities, using SBAR communication."
Patient Record Reviews and Interviews:
Patient #1:
1. On 7/9/12 at approximately 1300 hours, a white board with patient specific information was observed in, " the report room. " The Unit Manager and Nurse #1 stated that unit procedure required each on-coming shift to review the white board at the beginning of the shift and that recent patient falls, including any from the last shift, would be noted on this board. Both staff verified that no falls were noted at the time.
2. On 7/9/12 at 1317 hours, nurse #2 and the Unit Manager stated that patient #1 had just sustained his first fall (during this hospitalization) while attending a Psychotherapy group session in the unit dining room. Patient #1 ' s record indicated diagnoses of Parkinson ' s and Memory Disturbance.
3. On 7/9/9/12 from 1230-1630 hours, record review revealed that patient #1 had an unreported fall on 7/8/12. This fall was not noted on the white board and a, "Safety Call Out" for this fall was not found. This unreported fall was noted in a progress note by Nurse #3, dated 7/8/12 at 0004, stating: " At 2235 patient (#1) spat out his Depakote and entered nurses ' station, pushing and yelling. Seemed confused. When assisted into wheelchair back in hall, he kicked at PCA and threw himself on the floor. Yelling, fearful, making delusional statements, calling for help. Given IM with the assistance of staff and security. "
4. The above findings were verified by the Unit Manager on 7/9/12 and 7/10/12.
Patient #4:
1. On 7/10/12 from 0800-1500 hours, review of patient #4 ' s closed medical record revealed that only one fall was reported and processed as a Safety Call Out. That (untimed) report was dated 4/24/12. The patient required transfer to the Emergency Department for treatment of head wounds after the patient was " found in doorway, lying on his back. " The report recommended 1:1 supervision while awake.
2. A progress note dated 4/23/12 states: " 0715 pt. (patient) found sitting on floor, slumped against chair ...bilateral knees skinned with small amount of bleeding ...on 1:1 supervision. " No Safety Call Out for this fall was found. There was no explanation of why the patient was found on the floor while on 1:1 supervision.
3. There was no documentation of a post-fall huddle.
4. The above findings were verified by the Unit Manager on 7/10/12 at 1430 hours.
Patient #2:
1. On 7/10/12 from 0800-1330 hours, review of patient #2 ' s clinical record and a facility report dated 6/18/12 revealed a diagnosis of dementia and documented the need for assistance with toileting. The report documented a fall on 6/14/12 and recommended that a safe bed alarm system be installed. A 6/17/12 note by the Unit Manager stated that bed alarms would be delivered on 6/18/12.
2. On 7/10/12 at approximately 1430 hours, the Unit Manager stated that a bed alarm was not available for use by patient #2 prior to discharge. The patient remained at the facility through 6/25/12.
Patient #3:
1. A facility Incident report dated 4/28/12 indicated that patient #3 was found on the floor following a fall from his wheelchair. He was noted to be a frail dementia patient who does not remember his physical limitations.
2. On 4/29/12 the patient was documented as oriented to place only.
3. On 4/29/12 staff completing patient #3 ' s Morse Fall Risk Score placed him in the low risk range, noting no problems with gait or transfer and having no secondary diagnosis that would increase fall risk. The Unit Manager agreed that these items should have been scored, resulting in a higher risk score.
4. There was no documentation of a post-fall huddle.
5. The above findings were verified by the Unit Manager on 7/10/12 at 1430 hours.

Based on observation and interview the facility failed to ensure geriatric chairs were maintained to an acceptable level of safety for 2 geriatric chairs available for patient use. Findings include:

On 7/9/12 at approximately 1245 hours, 2 unsafe geriatric chairs were observed on the unit. A geriatric chair in room 126 did not lock when fully extended instead, and it could be physically rocked when fully extended. Another pink floral geri-chair adjacent to the nurse ' s station, had an open space between the chair and leg rest that allowed for a patient ' s legs to potentially be caught when going from a reclining to sitting positions. In addition, when sitting upright the chair seat sloped forward placing patients in an unnatural position. These observations were confirmed with the Unit Manager.