HospitalInspections.org

Based on record review, interviews and observations, the Hospital ' s corrective actions to reduce the incidence of patient falls were not consistently implemented for 2 Patients: (Pt.) Pt #1 and #10 from a sample of 10.

Findings include:


1) The Hospital ' s Corrective Action Plan indicated that on 8/14/12, a Safety Alert was sent to all Nursing Managers and Nursing Directors. The Safety Alert highlighted 3 recent falls, in which Pt. #1 had 2 of the 3 falls. The alert included reminders to always use the STAR acronym which means: Stop, Think, Act and Review to ensure all fall prevention interventions were in place. The Corrective actions also included that the Resource RN ' s would make rounds on all patients to ensure that all fall risk precaution intervention are in place.

2) The Policy and Procedure for Falls Prevention included Fall Prevention Interventions (Attachment A) of the Fall Prevention Policy. The interventions included the posting of Signage indicating which patients were at High Fall Risk.

Pt. #1 ' s Fall Risk Score dated 8/10/12 was 8 (Fall Risk Score greater than 5 indicates High Fall Risk).

Pt. #10 ' s Fall Risk Score dated 9/17/12 was 8

A tour of the nursing unit was conducted on 9/17/12 at 8:12 A.M.

Observations included Pt. #1 and Pt. #10 ' s rooms. Both Pt. #1 and Pt. #10 were on precautions for high fall risk. However, there was no signage posted as required per policy.

3) RN #2 was interviewed in person on 9/17/12 at 9:35 A.M. RN #2 did not indicate that her duties included rounding on all patients to ensure that all fall risk precaution interventions for patients were in place.

Based on record review, interviews and observations, the Hospital failed to ensure that 2 patients: Patient (Pt.) #4 and #8, from a sample of 10 patients, were assessed upon admission for falls risk according to Hospital Policies and Procedures.

Findings include:

1) The Falls Prevention Policy indicated that all patients will be assessed for falls risk at the time of admission. The Hendrich II Falls Risk Assessment Tool (an assessment tool to determine patients at high risk for falls) will be completed.

2) Pt. #4's Initial Nursing Admission dated 9/13/12 indicated that the Hendrich II Falls Risk Assessment Tool was not completed at the time of admission at 3:00 A.M.

Pt. #8's Initial Nursing Assessment dated 9/16/12 indicated that the Hendrich II Falls Risk Assessment Tool was not completed at the time of admission at 9:18 P.M.