HospitalInspections.org

Based on document review and interview, the facility failed to follow established policies and procedures after a patient safety (fall) situation for 1 of 10 (P1) patient MR's reviewed.

Findings include:
1. Facility policy for: "Adult Progressive Mobility and Safe Chairing Practices System Nursing Protocol," Policystat ID: 5640054, directs staff to utilize lift equipment, or a gait belt in assisting patient transfers.

2. Facility policy for "Falls Prevention," Policystat ID: 5990657, directs F1 Nursing staff that a "Debriefing and documentation should occur as soon as possible after a fall occurs." and "assess the patient for injury, notify the practitioner, document the fall event, complete an incident report, complete a post fall huddle, if needed reassess fall risk and update patient's care plan."

3. Review of P1 MR indicated a lack of documentation of a patient fall on 1/15/2020.

4. Review of facility incident report log item#00045649 on 1/16/2020 at 2325 hours, indicates a report was filed by the intensive care unit charge nurse due to P1's death being considered a coroner's case. A fall in the Post Anesthesia Care Unit is described without any reference to supporting reports or MR documentation.

5. In interview on 2/10/2020 at 1330 hours, S2, (Quality Director) confirmed that facility falls protocol, reporting practices, and policies were not followed by nursing staff in the case of P1 on 1/15/2020.

6. In interview on 2/10/2020 at 1240 hours, S3 (Preoperative and Postoperative Manager) confirmed hearing about the fall on 1/15/2020 in the PACU area. S3 felt that since the nurse (S5) involved was a resource nurse, it was the responsibility of the resource team's manager to ensure a report was completed.

7. In interview on 2/10/2020 at 1350 hours, S4 (Certified Surgical Technician) confirmed they were present to assist during the fall incident on 1/15/2020. S4 indicated that 4 personnel were present, and confirmed that P1 went limp and was lowered to the floor. Additional personnel (4) were gathered for a total of 8 with a gait belt to lift P1 from floor to wheelchair.