HospitalInspections.org

Based on facility policy review, medical record review, review of facility documents, observations, and interviews, the facility failed to implement falls precautions for 3 patients (#3, #9, and #10) of 7 patients reviewed for falls.

The findings include:

Review of facility policy "FALLS RISK & PREVENTION," last reviewed 8/2018, revealed "...High Level Risk: 46 or above on the Morse Fall Scale..." Continued review revealed interventions for patients with a high fall risk included "...Yellow fall risk armband placed on patient's arm...High Fall Risk Signage in patient's room...Patient transfers with a gait belt...Bathroom assistance with staff assistance...Patient must be attended to at all times while toileting or bathing...The Imaging Services staff are responsible for...Assess patient visually for any physical impairments and offer assistance as needed...Assess patients for yellow fall risk bracelet and accommodate accordingly with multiple staff assist..."

Medical record review revealed Patient #3 was admitted to the facility on 3/20/19 with diagnoses including Coronary Artery Disease Post Bypass Surgery, Mitral Valve Insufficiency (leaking heart valve), Hypertension, and Parkinson's Disease (nervous system disorder causing tremors and poor balance). Further review revealed Patient #3 had Coronary Artery Bypass Graft (open heart) surgery on 3/20/19 and a Pacemaker Implantation on 3/27/19. Continued review revealed the patient was assessed as a "...High Risk..." on admission to the facility and remained a high risk for falls until his discharge on 3/29/19.

Review of a facility document, POST FALL/HUDDLE, dated 3/26/19 at 6:35 AM revealed while Patient #3 was in the radiology department for a chest x-ray, staff had the patient stand unattended for the chest x-ray and "...he [patient] let go of handle and stumbled backward till he feel to the ground...had a Fall risk armband..." Further review revealed the patient had no mobility support equipment such as a gait belt or walker while he was standing. Continued review revealed "...Do not attempt to stand up patient for erect x-rays if they are a fall risk..." Further review revealed the patient was uninjured from the fall.

Medical record review of a Physician's Discharge Summary note dated 4/8/19 at 12:21 PM revealed "...Fall precautions were in place. The patient [Patient #3] did have a fall, but there was no obvious injury..."

Medical record review revealed Patient #9 was admitted to the facility's Emergency Department (ED) on 7/12/19 at 10:24 AM with complaints of left hip pain following a fall a week prior. Continued review revealed the patient was assessed with a high risk for falls and fall precautions were initiated.

Review of a facility document, Imaging/Radiology Falls List, dated 3/37/19 to 7/23/19 revealed Patient #9 was listed on the falls list. Further review revealed the patient had a fall on 7/12/19. Continued review revealed "...During an Xray exam [Patient #9] was asked if he could stand and he stated he could. When attempting to stand his knees buckled and he slid to the floor..."

Review of a facility document, POST FALL/HUDDLE, dated 7/12/19 at 12:30 PM revealed Patient #9 was identified as a fall risk with a "...yellow bracelet..." Further review revealed "... [staff] will not stand patients identified as a fall risk..." Continued review revealed the patient had no mobility support equipment such as a gait belt or walker while standing.

Interview with the Manager of Nuclear Medicine on 7/23/19 at 10:00 AM, in the Administration Conference Room, revealed on 3/26/19 all imaging staff was verbally instructed to not stand patients who were fall risks. Continued interview confirmed patients at risk for falls were not to stand for X-rays.


Medical record review revealed Patient #10 was admitted to the facility on 7/14/19 with diagnoses including Sepsis (a systemic infection), Abscess (infected wound) on the Left Anterior Thigh, Acute Kidney Injury, Uncontrolled Diabetes, and Cirrhosis (liver disease). Continued review revealed on 7/22/19 the patient was assessed with a high risk for falls and fall precautions were initiated.

Observation of Patient #10 on 7/23/19 at 2:58 PM, in the patient's room revealed there was no Fall Risk signage on the patient's door or in the patient's room. Continued observation revealed the patient was not wearing a yellow fall risk bracelet.

Interview with Nurse Manager #1 on 7/23/19 at 2:58 PM, outside Patient #10's room, confirmed Patient #10 was assessed as a high risk for falls and was on fall precautions. Further interview confirmed the patient should have a yellow fall risk bracelet on the wrist and there should have been a fall risk sign on the door to the patient's room.