HospitalInspections.org

Based on record review and staff interviews, the facility failed to supervise patient care and follow their Fall Prevention policy/procedure and in 1 (SP#4) of 2 sample patients who fell multiple times.

The findings:

On 11/01/2019 at 5:12 AM- the Nurses Notes showed Nurse K completed a fall risk screening for sample patient (SP) #4. Total fall risk score was 19. A score of greater or equal to 10 = AT RISK for fall per hospital Fall Prevention policy.

On 12/02/19- the Progress Notes showed Physician A ordered Fall Precautions for SP#4.

On 12/02/19 at 4:50 PM- the Nurses Notes showed Nurse G reported, SP#4 found on the floor by the bed at this time. Matts on the floor. Patient denies any pain and not note of any injury.

On 12/04/19 at 2:47 PM the Nurses Note revealed Nurse B completed the fall risk screening for SP#4. Total risk score is 19. Patient at risk for fall per hospital policy.

On 12/04/19 at 3:10 PM the Nurses Note showed Nurse H wrote, found patient on floor; no injuries noted.

On 12/08/19 at 3:30 PM the Nurses Notes showed Nurse D wrote "patient was found on the floor at bed side.

On 12/12/19 at 8:20 AM the Nurses Note showed Nurse D completed SP#4 Fall Risk Screening. Patient had a total fall risk score of 21. SP#4 is At Risk for fall per hospital fall prevention policy.

On 12/23/19 the Progress Notes showed Physician B wrote the following medical order: no need for a sitter.

On 12/26/19 at 1:15 PM the Nurses Notes showed Nurse F wrote "patient found in the room floor at bedside. No sign or symptom of injury at this time.

On 1/14/2020 at 10:11 AM during the interview, the Chief Clinical Officer/Patient Safety Officer stated that not all the beds had bed alarm. She does not know if SP#4 bed alarm was ON. She states that we did all that we can to prevent the falls: had one sitter for one day due to the patient been aggressive and agitated, medications been adjusted multiple times. The sitter was discontinued by the Psychiatrist. She states that the patient is always trying to get out of bed. As far as staffing changes, she states that there was an increase in rounding. She states that there is no written policy on rounding. Finally, the medication changes have reduced the patient agitation.

On 01/14/2020 11:00 AM during the interview, Nurse I stated that SP#4 fall precaution measures included floor matt, 3 rails up (bed), conduct evaluation assessment and place patient near the nurse's station. High fall risk patients, the rounding will be conducted every 30 minutes to one hour as needed. She also states that none of the Unit beds have bed alarm.


Review of Hospital Fall Prevention. Policy number H-PC 03-008, Release Date: 6/20/2019. The purpose of the policy is "use of a multi-interventional Fall Prevention program that utilizes fall prevention and management practices consistent with clinical practice standards aim at reducing fall risk without compromising the mobility and functional independence of a patient, minimization of patients' fall risk may be effective in reducing the occurrence of patient falls during hospitalization". A fall risk score greater or equal to 10=At Risk. Those patients identified as being "at risk" for falls will have additional interventions added to their plan of care in an effort to prevent falls. These additional interventions are in addition to the standard fall prevention interventions that will be follow on all patient upon admission. Per policy, these additional interventions include, but not limited to:
1. Use of Bed Alarms/Chair alarms
2. Consider family staying, or changes needed in staffing
There is no documentation that the staff implemented any one of the above fall prevention interventions except of one day that a sitter was assigned to the patient and latter discontinue by the Psychiatrist.