HospitalInspections.org

Based on policy review and medical record review, the facility nursing staff failed to document the circumstances surrounding two inpatient falls, and failed to document an immediate post fall assessment in the patients' medical records.

Findings:
On 3/22/17, during a medical record review, it was noted that in a sample of patients who fell, one on 9/6/16 and one on 12/29/16, nursing staff who were caring for the patients, failed to document the circumstances of the fall. On 9/6/16, an 86 year old male fell during the evening change of shift. Nursing staff failed to document the circumstances of the fall. Neither the day shift nurse nor the nursing supervisor documented an immediate post fall assessment.

A 72 year old male who was admitted on 12/29/16, fell on 12/30/16 at 3:45 PM. Nursing staff failed to document the circumstances of the fall and failed to document an immediate post fall assessment.

Facility policy, "Patient Fall Prevention Program", reviewed 9/6/16, states that nursing staff must document the "Details of the fall situation" and document a "Patient post fall physical assessment."

Based on document review and interview, the facility failed to investigate and analyze a patient fall.

Findings:
On 9/1/16, an 86 year old male was admitted to the facility for intractable vomiting. Nursing staff classified the patient as a "high risk" for falls. the patient was left unattended in the bathroom and fell striking his head.

The fall occurred on 9/6/16. On 3/22/17 at 10:30 AM, representatives from the facility's nursing administration and from the facility's quality assurance program stated that no investigation had been conducted regarding the fall that had occurred 6 months earlier.

The facility policy, "Patient Fall Prevention Program", revised on 2/5/14 and reviewed on 9/6/16, states that', "All falls are reviewed by Nursing Quality Management Services, tracked, trended and actions taken as appropriate based on review".

Based on policy review, medical record review and interview, the facility nursing staff failed to provide care based on a patient's needs and the facility's policy for fall prevention; staff also failed to track and document the use of indwelling urinary catheters.

Findings:
During a medical record review conducted on 4/3/17, it was noted that on 9/1/16, Patient #1 was assessed as a "high risk" for falls. The patient scored a 40 on the falls risk scale. Patients who are deemed to be at 15 points or higher are considered "high risk" individuals. On 9/1/16, nursing staff documented in the patient's plan of care that the patient needed to be observed when out of bed. Subsequent nursing staff did not include that intervention in their documentation of the daily plan of care.

During an interview conducted on 3/22/17 at 11:10 AM, a nursing supervisor stated that on 9/6/16, nursing staff had walked the patient to the bathroom and then left the patient unattended.

During a review of the facility policy titled, "Patient Fall Prevention Program", revised 2/5/14, the following was noted:
· Section B, item #2, under Assessing Fall Risk, states, "An adult patient that scores 15 or greater on the fall risk assessment tool is to be placed on Fall Precautions."
· Section C, item #6, under Implementing Fall Precautions states that, "Any patient deemed to be at risk for falls must not be left alone while on the commode or in the bathroom."

Findings:
The facility policy, "Indwelling Urinary Catheter (Foley) Care and Management", revised 11/11/16, directs staff to discontinue urinary catheters as soon as they are no longer clinically indicated. Policy also requires that staff document the indication that necessitates continued catheter use.

During a 3/23/17 medical record review, two inpatients, admitted to the Universal Care Nursing Unit, were identified as having urinary catheters. On 3/23/17, at 1:30 PM, Universal Unit management was unable to provide a medical reason for the use of the catheters. Nursing management was also unable to demonstrate nursing documentation regarding the medical necessity for the use of the catheters.