HospitalInspections.org

Based on staff interviews and document review the facility failed to ensure that 1 of 12 patients, Sample patient #6, received care in a safe setting.

This failure resulted in Sample patient #6, a moderate fall risk patient, falling out of the wheelchair 2 times, causing injury to the patient.

Findings:

Policy

According to the facility fall policy, adult patients are assessed to be at risk for a fall when he or she has a score of six (6) or greater on John Hopkins Fall Risk Tool (JHFRAT). Fall risk is determined at low or no risk (score of 0 to 5), moderate (score of 6 to 13) or high risk (score greater than 13). High Fall Risk: Use direct visual access.

The facility did not implement identified interventions to prevent a patient falls.

a) On 05/13/14, a review of medical record for sample patient #6 was conducted. The patient was admitted to the Rehabilitation Unit on 12/12/13. During an interview with the Director of the Rehabilitation Unit on 5/14/14 at 1:33 PM, it was confirmed that on admission to the unit, the patient was assessed to be a moderate fall risk with a score of 13, based on the JHFRAT. One of the safety measures documented in the patient care plan was the patient was not to be left alone while up in a chair. The patient's medical record revealed that on 12/14/13, the patient was up in a wheelchair having lunch in his/her room and was found at approximately 12:00 PM, on the floor by nursing staff. The medical record documented the patient ' s recall of the fall and that the patient struck her left cheek. The record also revealed on 12/14/13, at approximately 7:00 PM, the patient was at the nurses ' station in a wheelchair and got up to walk and fell. The patient did hit his/her head, sustained a laceration to her left eyebrow with swelling and bruising, was seen by a physician, a suture was placed and a CT scan of head and cervical spine was performed with no changes identified.


b) On 05/14/14 at 1:30 p.m., an interview with the Director of the Rehabilitation Unit was conducted. The Director stated that the patient's family had been in the patient's room and had been requested to notify staff when they were leaving the patient. Family failed to notify staff that they were leaving as requested. S/he stated that if the patient's family left or were not present while the patient was up in a wheelchair that they would bring the patient to the nurses ' station to keep an eye on him/her. The Director stated on 12/14/13 at approximately 12:00 PM , the patient recalled bending over to pick up a piece of food that had fallen on the floor and tipped the wheelchair over falling to the floor sustaining an injury to his/her left cheek. Facility staff were unaware the patient was alone in his/her room in a wheelchair.

Based on staff interviews and document review the facility failed to ensure that 1 of 12 patients, Sample patient #6, received care in a safe setting.

This failure resulted in Sample patient #6, a moderate fall risk patient, falling out of the wheelchair 2 times, causing injury to the patient.

Findings:

Policy

According to the facility fall policy, adult patients are assessed to be at risk for a fall when he or she has a score of six (6) or greater on John Hopkins Fall Risk Tool (JHFRAT). Fall risk is determined at low or no risk (score of 0 to 5), moderate (score of 6 to 13) or high risk (score greater than 13). High Fall Risk: Use direct visual access.

The facility did not implement identified interventions to prevent a patient falls.

a) On 05/13/14, a review of medical record for sample patient #6 was conducted. The patient was admitted to the Rehabilitation Unit on 12/12/13. During an interview with the Director of the Rehabilitation Unit on 5/14/14 at 1:33 PM, it was confirmed that on admission to the unit, the patient was assessed to be a moderate fall risk with a score of 13, based on the JHFRAT. One of the safety measures documented in the patient care plan was the patient was not to be left alone while up in a chair. The patient's medical record revealed that on 12/14/13, the patient was up in a wheelchair having lunch in his/her room and was found at approximately 12:00 PM, on the floor by nursing staff. The medical record documented the patient ' s recall of the fall and that the patient struck her left cheek. The record also revealed on 12/14/13, at approximately 7:00 PM, the patient was at the nurses ' station in a wheelchair and got up to walk and fell. The patient did hit his/her head, sustained a laceration to her left eyebrow with swelling and bruising, was seen by a physician, a suture was placed and a CT scan of head and cervical spine was performed with no changes identified.


b) On 05/14/14 at 1:30 p.m., an interview with the Director of the Rehabilitation Unit was conducted. The Director stated that the patient's family had been in the patient's room and had been requested to notify staff when they were leaving the patient. Family failed to notify staff that they were leaving as requested. S/he stated that if the patient's family left or were not present while the patient was up in a wheelchair that they would bring the patient to the nurses ' station to keep an eye on him/her. The Director stated on 12/14/13 at approximately 12:00 PM , the patient recalled bending over to pick up a piece of food that had fallen on the floor and tipped the wheelchair over falling to the floor sustaining an injury to his/her left cheek. Facility staff were unaware the patient was alone in his/her room in a wheelchair.