HospitalInspections.org

Based on policy review, record review and staff interview the hospital failed to supervise, monitor, assess a patient health status, and promptly notify the physician of a patient fall for one of twenty sampled patients (patient #1).

Findings include:

- The hospital's policy "Fall, Patient/Visitor Assessment/Intervention Following" reviewed on 3/6/12 at 3:30pm directed "...A Registered Nurse (RN) shall immediately examine a witnessed/alleged fall for injury/emergency care...The RN shall immediately notify the physician for patient falls, resulting in anything more than a minor injury and obtain orders for treatment..."

- Patient #1's medical record review on 3/6/12 at 3:00pm revealed an admission date of 2/18/12 with diagnoses of Pneumonia and Atrial Flutter (abnormality of the heart rhythm). Patient #1's medical record indicated hospital staff found patient #1 on the floor in their bathroom on 2/14/12 at 10:20am. Nursing staff B, documented on 2/24/12 at 10:20am "...Heard call for help from the bathroom. Patient found on floor by stool. Alert and oriented. Assisted back to bed by RN and CNA. Assessed for any injuries. Doctor notified. Orders received and followed..." The medical record lacked evidence of documentation for the type or extent of injuries, the areas of injury, or the patient's vital signs.

Review of the hospital's switchboard page log on 3/7/12 at 8:20am revealed nursing staff B placed a page to patient #1's primary care physician, on 2/24/12 at 11:26am (an hour after the fall).

The medical record indicate the first set of vital signs obtained on patient #1 after their falls occurred at 12:00pm, one hour and forty minutes after the fall.

- Administrative staff A, interviewed on 3/7/12 at 1:30pm acknowledged patient #1's medical record lacked evidence of a nursing assessment including extent of injuries, the areas of injury, or the patient's vital signs.

Hospital nursing staff failed to supervise, monitor, assess a patient health status, and promptly notify the physician of a patient fall for patient #1.

Based on policy review, record review, and staff interview the hospital failed to adequately identify and implement intervention in the care plan for one of twenty sampled patients with a high risk potential for falls (patient #1).

Findings include:

- The hospital's policy "Plan for Nursing Care" reviewed on 3/5/12 at 4:00pm directed "...The plan of care shall be based on the RN (Registered Nurse) assessment, addresses the physical, emotional, social needs ..."

- The hospital's Fall Risk assessment critiria reviewed on 3/7/12 at12:30pm include the patient's mental status, bowel and bladder habits, medications, length of stay in the hospital, hearing and visual deficits, as well as history of falls.

- Patient #1's medical record review on 3/6/12 at 3:00pm revealed an admission date of 2/18/12 with diagnoses of Pneumonia and Atrial Flutter (abnormality of the heart rhythm). The nursing admission assessment on 2/18/12 at 11:48pm indicated patient #1's history included neurological disorders, seizures, memory loss, vertigo, weakness, and falls with fractures of the left hip and wrist in August 2011. Physician documentation on 2/19/12 included the patient's history of frequent falls recently and sustained both a hip fracture and bilateral arm fractures. Past medical records included hospital visits 7/3/11 for a fractured distal left radius after a fall and 8/1/11 for a fractured left hip after a fall.

- The patient #1's fall risk assessment, completed three times a day classified the patient as a low risk for falls from 2/19/12 at 1:19am through 2/26/12 at 8:11am. Each fall risk assessment failed to include the patient's history of falls. The nursing assessment completed on 2/24/12 at 8:00am included recent memory impairment, generalized weakness, and both hands and hip fractured in the past.

- On 2/14/12 at 10:20am nursing staff found patient #1 on the floor of the bathroom. Patient #1's medical record revealed documentation on 2/24/12 at 10:20am "...Heard call for help from the bathroom. Patient found on floor by stool. Alert and oriented. Assisted back to bed by RN and CNA. Assessed for any injuries. Doctor notified. Orders received and followed..." After patient #1 fell hospital nursing staff failed to reassess the plan of care to identify the patient as a high risk for falls and implement preventative interventions until 2/26/12 at 4:14pm (2 days after falling in the hospital).

Administrative staff A, interviewed on 3/7/12 at 1:30pm acknowledged patient #1's fall risk assessment failed to include patient #1 ' s history of falls as criteria to identify the patient's potential for falls.

Hospital nursing staff failed to adequately identify and implement intervention in the care plan for patient #1 with a high risk potential for falls.