HospitalInspections.org

Based on interview and record reviewed for four of ten sampled patients (Patient #1, #2, #4 and #9) the hospital failed to ensure that nursing assessments were performed and interventions were implemented to reduce patient fall risks.

Findings include:

The Hospital policy and procedure related to Fall Prevention, dated October 2015, indicated that each patient will be assessed for fall risk and an individual care plan will be developed to mitigate the risk and potential of injury. The policy indicated that Emergency Room and In-patients will be screened for fall risk using the Morse Falls Scale (a scoring scale to identify the fall-prone patient) every shift. The policy indicated that a bed and or a chair alarm will be used for a patient with a score greater than 45.

The Hospital Nursing Education, not dated, regarding falls indicated that the intervention of using a bed/chair alarm should be used.

Patient #1 was admitted to the Emergency Department's Behavioral Health Unit on 2/13/18 for psychiatric evaluation and placement into a Psychiatric Unit. Patient #1 was assessed on 2/13/18 at a low risk for falls. On 2/15/18 Patient #1 experienced an intracranial bleed (bleeding into the brain) after a fall. Patient # 1's fall risk was re-assessed after the fall with injury.

Patient #1 was assessed using the Morse Fall Scale during his/her initial nursing assessment, dated 2/13/18, as required; however, the nursing staff failed to document a falls prevention assessment every shift until it was documented three days later after Patient #1 fell.

Patient #2 presented on 9/13/17 with altered mental status and was assessed at a moderate risk for falls. Patient #2's Morse Fall Scale failed to include that Patient #2 used an assistive device which would have changed his/her score to a high risk for falls and required additional fall prevention measures.

Patient #4's Emergency Room Nursing Assessment, dated 11/3/17 at 5:28 P.M., indicated that Patient #4 was identified to be a high fall risk, Patient was assigned a score of 70. However, there was no documentation to indicate a bed alarm was implemented. Patient #4's Emergency Room Nursing Note, dated 11/4/17 at 1:12 A.M., indicated that his/her nurse heard a loud thud sound from Patient #4's room, went to Patient #4's room and observed Patient #4 with a laceration of his/her forehead climbing back onto his/her bed.

Patient #9's Emergency Room Nursing Note, dated 3/5/18, indicated that a Fall Risk Assessment and a Morse Fall Score was not completed.

The Surveyor interviewed the Chief Nursing Officer (CNO) on 6/18/18 at 8:30 A.M. and throughout the Survey. During Patient #9's record review with the Surveyor, the CNO said Patient #9's initial nursing assessment was incomplete and that Patient #9 was not assessed for a fall risk as required by nursing policies and procedures and was not assigned a Morse Fall Risk Score.

Patient #9's Emergency Room Note, dated 3/6/18 at 2:44 P.M., indicated that a bang noise was heard coming from Patient #9's room and that he/she was found on the floor in the corner of the room.







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