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Based on interview and record review the hospital failed to ensure that nursing documentation was complete in identifying the course and results of care and treatment after experiencing a fall for one for applicable patient (Patient #1). Findings include:

On 10/31/23 Patient #1 underwent significant abdominal surgery. Post operatively, Patient #1 demonstrated a slow recovery. After being evaluated on Postoperative Day 3 (POD #3) by Physical therapy it was noted Patient #1 demonstrated issues with balance, gait, mobility and impaired self care. During the evaluation the physical therapist states: "During all functional activities noted the patient was provided with manual assist and education via a combination of verbal and demonstration...Patient instructed in how to appropriately pace activity now and in the future. Recommend for patient to be OOB (out of bed) and ambulate as tolerated with nursing assist and rolling walker". Patient #1 was considered a Fall Risk.

On the early morning at 11/4/23, Patient #1 was reportedly found on the floor in his/her hospital room. The medical record is unclear if the patient was ambulating to the bathroom, returning back from the bathroom or the actual fall occurred in the bathroom. After being found on the floor a Surgical Resident was contacted and evaluated the patient for injury. Patient #1 informed the Surgical Resident s/he "..had gotten up to use the bathroom......and as s/he was walking towards the bathroom, felt himself/herself falling backwards......states s/he bent his/her knees and slowly descending to the ground". No injuries were identified.

The patient's family described a different scenario regarding the fall which occurred on 11/4/23. The family stated Patient #1 sent a text message to a family member after falling on the floor in the bathroom. Patient #1 asked family to call the nurse's station on Baird 6, to alert staff s/he required help. In the Post Fall DAR Report for 11/4/23 at 2:54 the nurse documents: "Pt assisted to bathroom by staff member and instructed to pull bathroom assist cord when finished per staff member. Pt. attempted to return to bed without assistance resulting in fall...." Per interviews on 9/11/24 at 3:00 PM, LNA #1 (Licensed Nursing Assistance) assigned to the unit on the night of 11/4/24 stated s/he did not recall a fall or being assigned to Patient #1. Further interviews on 9/12/24 neither LNA #2 at 1:00 PM or LNA #3 at 3:15 PM had any recall of the incident with Patient #1. All 3 LNAs were familiar with the Fall Precaution policy.

Per interview on 9/10/24 at 2:10 PM neither the Nurse Manager or the Assistant Nurse Manager on Baird 6 were able to confirm the record for Patient #1 was accurate regarding the fall incident. The nurse's documentation within the Post Fall DAR Note is reversed mixing the "Response" with "Actions", presenting a different scenario from what the Surgical Resident wrote on 11/4/23 after examining the patient and what family had reported in allegations associated with the fall. Whether Patient #1 was instructed to pull bathroom assist cord on 11/4/23 when finished in the bathroom; or whether staff assigned failed to remain with Patient #1 as a fall precaution is also unknown. The medical record does not provide the complete information to ensure the safe provision of care had been provided and allowing a closer review of ensuring patient safety and staff awareness for maintaining Fall Precautions.


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