HospitalInspections.org

Based on staff interview and document review, it was determined the hospital failed to ensure all staff adhered to the policies and procedures of the hospital. Specifically, nursing staff failed to adhere to hospital policy related to fall prevention in two (2) of four (4) medical records reviewed in the survey sample (Patient #'s 2 and 5).

Findings:

The hospital's policy, Falls Prevention Policy was reviewed and reads in part, "Assessment: Morse Fall Risk Assessment and Falls Predictive Analytics (FPA) tool. a) Inpatients and observation patients, including Behavioral Health Units, will be assessed by nursing according to the Morse Fall Risk Assessment and Falls Predictive Analytics (FPA) tool upon: b) Initial nursing assessment (Morse will only be used for admission assessment) for the first 12 hours....4. Kinder 1 Fall Risk Emergency Department Patients, 18 years of age and older, will be assessed using the Kinder 1 Fall Risk Assessment Screening Tool during the triage process....Documentation: Each patient should have the following documentation within the EHR (electronic health record): 1. Fall risk assessment score per patient type as indicated. 2. Interventions as outlined above...Kinder 1 Fall Risk Assessment Tool: YES to any risk category = high fall risk."

The medical record for Patient #2 contained documentation that the patient presented to the ED with seizures on August 04, 2024. The patient was identified as a high fall risk on the Kinder 1 Fall Risk Assessment tool. The medical record failed to contain documentation that any interventions to prevent falls were implemented while the patient was in the ED.

The medical record for Patient #5 contained documentation that the patient arrived to the Emergency Department (ED) on August 2, 2024 at 12:11 AM with rectal bleeding. The ED nursing assessment indicated the patient was a high fall risk due to "nursing judgement" and fall risk interventions were put in place while in the ED. The patient was admitted to the intermediate care unit at 3:00 AM on August 02, 2024. Per hospital policy, a Morse Fall Risk Assessment should have been completed upon admission as an inpatient on August 02, 2024, but the medical record for Patient #5 did not contain documentation of the Morse Fall Risk Assessment being completed until August 05, 2024 at 8:00 AM.

An interview was conducted with Staff Member #2 on November 4 at 11:30 AM who indicated that the Morse Fall Risk Assessment should be completed on all inpatients upon admission. Staff Member #2 indicated all interventions to prevent falls should be documented in the medical record.