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Based on record review and interview the facility nursing staff failed to implement the nursing care plan for high risk for falls for 2 of 5 (#1, #4) patients who fell in the facility.

The findings included:

Interview on 6/3/10 at 9:30 AM with the Nurse Manager for the Intensive Care Unit (ICU) and 1st floor Med-Surg Unit revealed that the fall risk assessment is completed each shift by the nurse. Each nurse determines the fall risk for the shift and the interventions change with each assessment score. The fall risk assessments are documented in the record along with the care plan.

Review of the clinical record of Patient #1 revealed that the patient was admitted to the facility on 4/19/10 with shortness of breath and change in mental status. The patient was found on the floor on 4/23/10 at 7:50 AM in PCU. There was documentation in the record that there was a bed alarm on the patient at 7 am and the call bell was within reach. The bed alarm went off at 7:50 AM and the nurse responded to find the patient on the floor. The patient had a contusion on the side of the head. The patient's head apparently hit the side of the bedside table. The post fall investigation report documented that the bed alarm had been on and the need would continue. The physician and the family were notified of the fall. The physician ordered a Computerized Tomography (CT) scan of the head and arterial blood gases to be done. The CT result was no fracture or hemorrhage seen and the oxygen was increased as indicated by the blood gas report. Review of the fall risk assessment revealed that the patient was a high risk level 3 from admission. The patient was to have a bed alarm on and activated at all times. The documentation on that assessment record by the nurse on each shift revealed that the alarm was not activated. Additionally, after the patient was found on the floor, the document stated there was no alarm activated.

Review of the clinical record of Patient #4 revealed that the patient was admitted to the facility on 4/14/10 with generalized weakness as a result of very low potassium, metabolic acidosis as a result of bariatric surgery and the loss from 315 pounds to 127 pounds, acute and chronic renal insufficiency, bicarbonate wasting in the stools, malnutrition, B-12 deficiency, frequent falls at home, urinary tract infection, multiple infected wounds over various parts of the body that were unable to heal due to the malnutrition and renal failure, klebsiella pneumoniae, chronic anemia, and dysphagia due to candidiasis of the esophagus. The patient was placed in ICU on 4/15/10 due to high blood pressure. The physicians considered reversing the bariatric procedure but the patient was too frail to withstand the procedure. The patient fell in the hallway while in the facility on 4/22/10, sustaining a head injury. The report of the fall from the staff revealed that the patient had gone out to the parking lot and was smoking. The volunteer at the front desk notified the floor nurse and she came to escort the patient back to the room. As the patient navigated the traffic in the hallway, he bumped into a visitor and fell to the ground, hitting his forehead and sustaining a laceration over the eyebrow and a bruise to the cheek. The physician ordered a Computerized Tomography (CT) scan of the head and for the patient to be taken to the ER for suturing of the laceration. The CT result was no fracture or hemorrhage seen. Review of the fall risk assessment revealed that the patient was a high risk level 3 from admission. The patient was to have a bed alarm on and activated at all times. The documentation on that assessment record by the nurse on each shift revealed that the alarm was not activated. Additionally, after the patient fell, the document stated there was no alarm activated.

Interview on 6/3/10 at 11:30 AM with the Director of Performance Improvement confirmed that after the patients had fallen the bed alarms were documented as not in use.

Review of the current facility policy for Fall Prevention Protocol revealed that a safe environment would be provided for the patients; a fall risk assessment will be performed on admission and every 12 hours thereafter, the program will be implemented upon identification of a risk for falls, the intervention levels build on one another and are documented on the risk assessment signed by the nurses.

Based on record review and interview the facility nursing staff failed to implement the nursing care plan for high risk for falls for 2 of 5 (#1, #4) patients who fell in the facility.

The findings included:

Interview on 6/3/10 at 9:30 AM with the Nurse Manager for the Intensive Care Unit (ICU) and 1st floor Med-Surg Unit revealed that the fall risk assessment is completed each shift by the nurse. Each nurse determines the fall risk for the shift and the interventions change with each assessment score. The fall risk assessments are documented in the record along with the care plan.

Review of the clinical record of Patient #1 revealed that the patient was admitted to the facility on 4/19/10 with shortness of breath and change in mental status. The patient was found on the floor on 4/23/10 at 7:50 AM in PCU. There was documentation in the record that there was a bed alarm on the patient at 7 am and the call bell was within reach. The bed alarm went off at 7:50 AM and the nurse responded to find the patient on the floor. The patient had a contusion on the side of the head. The patient's head apparently hit the side of the bedside table. The post fall investigation report documented that the bed alarm had been on and the need would continue. The physician and the family were notified of the fall. The physician ordered a Computerized Tomography (CT) scan of the head and arterial blood gases to be done. The CT result was no fracture or hemorrhage seen and the oxygen was increased as indicated by the blood gas report. Review of the fall risk assessment revealed that the patient was a high risk level 3 from admission. The patient was to have a bed alarm on and activated at all times. The documentation on that assessment record by the nurse on each shift revealed that the alarm was not activated. Additionally, after the patient was found on the floor, the document stated there was no alarm activated.

Review of the clinical record of Patient #4 revealed that the patient was admitted to the facility on 4/14/10 with generalized weakness as a result of very low potassium, metabolic acidosis as a result of bariatric surgery and the loss from 315 pounds to 127 pounds, acute and chronic renal insufficiency, bicarbonate wasting in the stools, malnutrition, B-12 deficiency, frequent falls at home, urinary tract infection, multiple infected wounds over various parts of the body that were unable to heal due to the malnutrition and renal failure, klebsiella pneumoniae, chronic anemia, and dysphagia due to candidiasis of the esophagus. The patient was placed in ICU on 4/15/10 due to high blood pressure. The physicians considered reversing the bariatric procedure but the patient was too frail to withstand the procedure. The patient fell in the hallway while in the facility on 4/22/10, sustaining a head injury. The report of the fall from the staff revealed that the patient had gone out to the parking lot and was smoking. The volunteer at the front desk notified the floor nurse and she came to escort the patient back to the room. As the patient navigated the traffic in the hallway, he bumped into a visitor and fell to the ground, hitting his forehead and sustaining a laceration over the eyebrow and a bruise to the cheek. The physician ordered a Computerized Tomography (CT) scan of the head and for the patient to be taken to the ER for suturing of the laceration. The CT result was no fracture or hemorrhage seen. Review of the fall risk assessment revealed that the patient was a high risk level 3 from admission. The patient was to have a bed alarm on and activated at all times. The documentation on that assessment record by the nurse on each shift revealed that the alarm was not activated. Additionally, after the patient fell, the document stated there was no alarm activated.

Interview on 6/3/10 at 11:30 AM with the Director of Performance Improvement confirmed that after the patients had fallen the bed alarms were documented as not in use.

Review of the current facility policy for Fall Prevention Protocol revealed that a safe environment would be provided for the patients; a fall risk assessment will be performed on admission and every 12 hours thereafter, the program will be implemented upon identification of a risk for falls, the intervention levels build on one another and are documented on the risk assessment signed by the nurses.