HospitalInspections.org

Based on observation, staff interview, a review of five of five medical records (Patient [P1], P2, P3, P4 and P5) for patients identified as a fall risk and a review of facility documents, it was determined that the facility failed to ensure their "Falls Prevention Program" policy and procedure is implemented.

Findings include:

On 3/15/23 at 10:21 AM, a tour of the 3 South Annex unit was conducted in the presence of Staff (S1) and S4. During the tour, the following patient rooms had yellow falling star door signs placed outside of the room: 332A (P2), 332B (P5), 334A (P3), and 334B (P4).

At 10:38 AM, staff interviews were conducted with S4 and S6. S6 confirmed that the yellow falling stars signs located outside of the rooms of P2, P3, P4, and P5 were in place because those patients are identified as a moderate risk for falls based on the Johns Hopkins Fall Risk criteria. S4 also explained that patients identified as a moderate fall risk should wear a yellow wrist band. Upon further observation and interview with S4 and S6, it was determined that P2, P3, P4 and P5 did not have yellow wrist bands on. S1 then explained that the yellow wrist bands were out of stock and unavailable on the unit and that a yellow fall risk sticker should be applied to the patient's identification (ID) band in its place. P2, P3, P4, and P5's patient ID bands were then observed by S4 who stated that the yellow fall risk stickers were not present on any of their ID bands. S4 was then observed to place the stickers on all four patients ID bands.

At 12:35 PM, a review of facility policy and procedure titled, "Falls Prevention Program," last reviewed 1/9/23, states, "... Policy: ... 2. fall risk is assessed upon initial assessment and is re-assessed ... every shift ... Risk assessment for adult patients will be done using the Johns Hopkins Fall Risk criteria ... 3. Alternatively, patients in the following categories will have fall prevention interventions initiated as indicated regardless of risk assessment score. High Fall Risk - Patient has a history of more than one fall within 6 months before admission. ... Equipment: ... Risk Identification: Yellow wrist band and ... Yellow Falling Star signage for moderate risk; ... Procedure: 1. Fall Risk Assessment: All patients will have a screening assessment done by an RN ... at the time of initial assessment. ... 2. Fall Risk Re-assessment: All inpatients will be reassessed for fall risk every shift ... 5. Departmental Responsibilities: ... 3. Nursing Services: Registered Nurses are responsible for the implementation and oversight of individualized patient/resident fall prevention care as follows: ... Moderate Risk: ... Visual cues in place (yellow wrist band, yellow falling star door sign) ... High Risk: ... Activate Bed and Chair Alarms ..."

On 3/15/23 at 12:47 PM, a review of P1's medical record, date of admission 2/10/23, was conducted with S2 and revealed the following: The History and Physical dated 2/11/23 stated, "... patient ... brought to the emergency room by ambulance for evaluation of chest pain, weakness, diarrhea. the patient reportedly fell at home ... transferred to ICU [Intensive Care Unit] ..." The nursing admission fall assessment on 2/11/23 at 6:07 AM stated "Scoring exclusion criteria (JH [Johns Hopkins] Score): More than 1 fall within 6 months prior to arrival. ..." On 2/11/23 at 6:28 AM, the nursing flowsheet stated, "Fall Risk Interp (JH Score) ...: High Fall Risk ..."

Upon interview on 3/15/23 at 1:10 PM, S2 indicated that P1 would be identified as a high fall risk during the admission due to having had a recent fall at home within the past 6 months.

The nursing shift assessment on 2/20/23 at 8:00 PM stated, "Scoring exclusion criteria (JH Score [Johns Hopkins]): More than 1 fall within 6 months prior to arrival. ..." Review of the "Safety" portion of the "Patient Care Intervention" section of the Nursing Flowsheet on 2/20/23 at 8:00 PM stated, "Safety: Fall Kit implemented, Siderails up/brakes on/bed low, Call bell within reach, Fall Risk identified. Environmental Safety Implemented: Bed in low position, Call device within reach, Non-Slip footwear, Patient specific measures, Personal items within reach, Traffic path in room free of clutter, Upper/Half length side rails for bed mobility, Wheels locked ..."

The Nursing Progress Notes dated 2/20/23 at 10:10 PM stated, "pts [patients] light was on and when I went inside room, pt was found on the floor face down... RRT [Rapid Response Team] was called ..."

The nursing assessment on 2/20/23 at 8:00 PM, prior to the patients fall 10:10 PM, did not contain documentation that a bed/chair alarm was activated for P1 per the policy and procedure for a patient identified as a high fall risk. Staff #2 agreed with the finding.

The above findings are not in accordance with facility policy and procedure.