HospitalInspections.org

Based on observation, staff interview, review of four of six medical records (Patient [P] 3, P4, P5, and P6) for patients identified as a fall risk, and a review of facility documents, it was determined that the facility failed to implement their "Falls Prevention Program" policy and procedure.

Findings include:

On 09/10/24 at 10:30 AM, during a tour of the 4 Pavilion (4P) unit, in the presence of Staff (S) 1, Manager of Standards, Licensure and Accreditation, and Quality Resource Services, the following was revealed:

At 10:31 AM, Room 4523 had door signage indicating that P3 was a fall risk. S2, Assistant Director of 4P, explained that any patient identified as a fall risk will have a yellow wristband applied, yellow non-slip socks on, bed alarms in place, and fall risk signage outside of the patient room. At 10:32 AM, S2 the entered Room 4523 and confirmed that P3 was not wearing a yellow wristband and stated that the wristband should have been applied on admission.

A review P3's medical record indicated that the patient was admitted on 09/05/24 at 05:26 AM to the Intensive Care Unit (ICU) for septic shock. The Johns Hopkins Fall Risk Calculator indicated that the patient was deemed a "high" fall risk per the automatic high fall risk protocol. P3 was transferred to 4P on 09/08/24 at 11:12 AM and remained a high fall risk.

At 10:43 AM, P4 in Room 4530B and P5 in Room 4530A, had door signage indicating they both were a fall risk. At 10:45 AM, S4, a Registered Nurse (RN), entered Room 4530 and confirmed that P4 and P5 were not wearing yellow wristbands and stated that the wristbands should have been applied on admission.

A review of P4's medical record indicated the patient was admitted on 09/08/24 at 03:49 PM from the Emergency Department (ED) and arrived to 4P on 09/08/24 at 5:19 PM for dizziness, nausea, and vomiting. Initial Fall Risk Score of five (5) was recorded in the ED on 09/07/24 at 12:55 PM, which deemed the patient a "low" fall risk. On 09/8/24 at 6:53 PM, upon initial assessment on 4P, the fall risk score was 7, which deemed the patient a "moderate" fall risk. The patient remained a "moderate" fall risk during his/her admission.

A review of P5's medical record indicated the patient was admitted on 09/08/24 at 10:54 PM from the ED and arrived at 4P on 09/09/24 at 12:18 AM for the diagnoses of cystitis, generalized weakness, and altered mental status. Initial Fall Risk Score of 14 was recorded in the ED on 09/08/24 at 7:55 PM, which deemed the patient a "high" fall risk. The patient remained a high fall risk during the admission.

On 09/10/24 at 11:00 AM, a tour of the 4A unit was conducted in the presence of S1. During the tour, Room 4103A, had door signage indicating that P6 was a fall risk. At 11:05 AM, S6, a RN, stated that P6 was at high risk for falls due to seizures and that if patients are identified as a fall risk, they will wear a yellow wristband and yellow non-slip socks as fall precautions. S2 confirmed P6 was not wearing a yellow wristband and stated that it should have been applied on admission to the unit.

A review of P6's medical record indicated the patient was a direct admission to 4A on 09/09/24 at 07:24 AM for symptoms of syncope (fainting). The Johns Hopkins Fall Risk Calculator indicated that the patient was deemed a "high" fall risk and remained a "high" fall risk during his/her admission.

A review of facility policy and procedure titled, "Policy: Falls Prevention Program," Effective date 12/05/22, stated, "... Policy: ... Fall risk is assessed upon initial assessment and is re-assessed following any change in status, upon intra-facility transfer to another level of care ... A yellow sign will be placed on doorframe outside the patient room, yellow slip resistant socks and yellow wristband, indicating that the patient is a moderate risk for falls. A red sign will be placed on the doorframe outside the patient room ... slip resistant socks and yellow wristband, indicating that the patient is a high risk for falls ... ."