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Based on document review and interview the facility failed to insure the safety of the patient as evidenced by 1 of 1 patient fall with injury.


On 3/14/2011 at 9:30 AM a review of the medical record (MR) revealed: On 10/21/2010 the patient was found at home by her spouse on the bathroom floor. After Transfer to the Emergency Department she was evaluated with acute changes in level of consciousness. The initial CT revealed a very large right middle cerebral artery occlusion. She was admitted to the hospital for further medical management. Her Morse fall Risk assessment was 85 (45 or higher requires intervention for fall risk).

On 3/14/2011 at 9:00 AM a review of the spouse's statement revealed: 10/23/2010 the he left to get something to eat around 5:30 requesting the staff "keep an eye on my wife" upon his return approximately 6:00 PM the spouse found the patient in the floor near the bed side. Note: ALL pt rooms are visible from the nurses station.

On 3/14/2011 at 10:00 AM in the conference room Pt #1 MR revealed nursing documentation records the following entry. 1810 hours; Medical staff called to the pt's room by the pt's husband. Pt was found on the floor, pt was transported back into bed, pt assessed for injuries, hematoma to Left side of head, small abrasion to pt's bottom lip, bruising noted to pt's left shoulder, VS stable. family at bedside Dr notified of pt's condition , new orders given , bed alarm in place, will continue to monitor pt.

There was no documentation of nursing intervention for the patient after the fall to relieve the swelling to the head. There was no documented effort to provide comfort for the patient or the family after the fall. There was documentation the pt left the floor for the CT at 2100 hours, 3 hours after the fall.. There was no documentation of Neuro checks status posts fall with closed head injury. There was no education documented for the family. There was no follow up documentation reflecting a change in the care plan secondary to a fall. There was no documentation at all after the fall for two (2) hours. The documentation begins again at 2000 hours with every 2 hour vital signs, however there was no documentation that reflected a recent fall with injury. There was no reassessment documented of the patient injuries after 1810 hours. There was no description of color,or size of bruising. There was no follow up documentation for injuries resulting from the fall.
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A review of the Quality Improvement Complaint Record (completed 11/10/2010) confirms the spouse returned and found the patient on the floor at 1800 hours (6:00 PM).

On 3/14/2011 at 9:30 AM the Neurology consult dated 10/24/2011 revealed: The patient was alone in her room, unrestrained, the husband returned and found her on the ground. Bruising to the left forehead, lips and arm. CT of head showed new critical contusions Left frontal, left temporal & parietal lobes in the setting of evolving stroke.

On 3/14/2011 at 10:30 AM in the conference room an interview with the Director of Neuro/Critical care confirmed the bed alarm was not engaged. When asked if the bed alarm had been inspected and found to be damaged or otherwise not in working order, the reply was "no". The bed was not inspected because the alarm was found to be in working order. Further inquiry confirmed the bed alarm had not been properly engaged by the nursing staff. The staff failed to insure the safety of the patient.

Based on documentation and interview the facility failed to provide patient care in a safe setting based on one patient fall with injury.


On 3/14/2011 at 9:30 AM a review of the patient record revealed a fall was documented on 10/23/2010. The nursing documentation reveals the following at 1610 hours *pt report received, pt resting in bed with family at the bedside, will continue to monitor* at 1810 hours *medical staff called to the pt's room by the pt's husband, pt was found on the floor, pt was transported back into bed, pt assessed for injuries, hematoma to Lt side of head, small abrasion to pt's bottom lip, bruising noted to pt's Lt shoulder. VS (Vital Signs) stable, family at bedside, Dr. notified of pt's condition, new orders given, bed alarm in place, will continue to monitor the pt.* A physician order dated 10/23/2011 reflects *CT of head Now* The next Nursing documentation occurs at 2000 hrs * Report received from off going nurse. Pt awake, breathing regular & unlabored. Denies pain, no complaints at this time. Husband at bedside, being transferred to private room, awaiting transport to X-ray for CT of head*. The nurses documentation reveal the patient was not transferred to CT until 2100 hours. 3 hours after the documented fall. It was also revealed that the documentation for *Bed Alarm activated* was *yes* beginning 10/21/2010 at 1445 hours through 11/3/2010 1200 hours. The nursing documentation records the bed rails (3) were noted as up for the same time period.

On 3/14/2011 at 11:00 AM in the conference room a review of the facility policy for assessment/reassessment found in the Administrative manual reveals, under Purpose: # 3 We define assessment as analysis of the data collected for the formulation of a plan of care which will be evaluated and reassessed based in the patient diagnosis, area in which care is delivered, patient willingness to participate in his/her care and response(s) to previous care.
Further review of this policy page #16 Scope of Assessment-Nursing A. The patient will be assessed on admission to determine nursing care needs. The assessment will include the Patient Admission Assessment, Functional Health Assessment, Risk Assessment Screen and the Assessment of the Patient Care record. C.1. The RN will be responsible for prioritizing the patient's care needs and developing a plan of care utilizing information gathered from the patient, family members/significant others, physician, licensed staff, non licensed staff and other disciplines as appropriate.

There was no documentation of nursing intervention prior to the fall even though the patient's Morse fall scale was 85. (A score of 45 indicates intervention.) There was no documentation that nurses recognized the needs of a patient with altered neurological functioning. There was no on-going documentation of nursing assessment, Vital signs or intervention involving the patient's injuries after the fall (No ice to head for swelling). There was no on-going documented patient/family teaching to reduce future injury. There was no alteration in the patient care plan to reflect nursing interventions to reduce future falls.

Further review of documentation in the Quality review process revealed a Quality Improvement Complaint (QCI) Record which revealed the spouse had complained regarding his wife's fall. The document reflects the events surrounding the fall. The complaint identifies* Staff response* as the issue. The only intervention documented was*spoke of this incident with staff involved & stressed watching pt's carefully and fall prevention*. The QCI record reflects a recommended delay in the mandatory letter of response by one week as a personal conversation resolved the issue. There was no documentation of further Quality review process. There was no documentation of specific staff education. There was no documentation of staff discipline for policy violation. There was no documented plan to monitor staff documentation. There was no documentation of investigation into the 3 hour delay for CT services after a patient fall with visible injury to the head (Large hematoma to Lt forehead).

On 3/14/2011 at 10:30 AM in the conference room an interview with the Director of Neuro/Critical care confirmed the bed alarm was not engaged. When asked if the bed alarm had been inspected and found to be damaged or otherwise not in working order, the reply was "no". The bed was not inspected because the alarm was found to be in working order. Further inquiry confirmed the bed alarm had not been properly engaged by the nursing staff. This presented an unsafe setting for a mentally confused patient with left sided weakness who fell, with bed rails up x 3 sustaining bruising and contusions to the left forehead, lips and left shoulder as documented in the nursing notes.

An interview on 3/14/2011 at 1:00 PM in the conference room ,with the Director of Nursing Quality of care revealed no system was in place to insure the Nursing Department incident reports were reviewed, consistently by the Nursing Department. Incident reports are routinely sent to the Risk Management then to Quality/RN reviews then back to Risk Management. Risk Management tracks and trends the information and gives the information back to units. The specific Incident Reports may never be seen by the unit in which the incident occurred. There was no documentation the facility had acted on the information identifying this fall as a safety issue, there was no documentation environmental factors had been considered relating to this fall. There was no documentation that delayed services after the fall (CT-X-ray ) had been questioned. The lack of vital signs and neuro checks for the 2 hours after the patient fell was not identified as a significant nursing issue. The discrepancy in nursing documentation and Director of Critical Care/Neuro services findings was not addressed.

Based on document review and interview the facility failed to assess for restraint as evidenced by on of one patients.


On 3/14/2011 at 1:00 PM in the conference room the medical record (MR) was reviewed for Patient # 1. The MR record revealed after the patient fell on 10/23/2010 the Neurologist documented a recommendation to the spouse to begin using restraint.

Further review of MR revealed physician's telephone order for bilateral wrist restraint, vest restraint, bed rails X 4 and bed alarm. There was no nursing documentation assessing for least restrictive restraint. There was no physician documentation for daily assessment of restraint. There was no care plan reflecting the need for restraint or reassessment of restraint.

Interview with the Director of Critical Care services confirmed that the rails were pulled up and bed alarm engaged after the fall.

There is a physician's order for vest restraint however there is no nursing documentation that the vest restraint was applied. There is no documentation that an assessment for a vest restraint was completed.

The wrist restraints were consistently documented on at least a daily basis in the nurses notes. There is documentation they were applied to the patient's wrist on 10/25/2010 at 7:30 but they are not tied to the bed.