HospitalInspections.org

Based on document review and interview, the facility failed to ensure a registered nurse supervised the care being provided to patients related to falls for 1 of 10 patients (patient #1).

Findings include:

1. Facility policy titled "FALL PREVENTION PROTOCOL" last reviewed/revised 1/17 indicated low risk interventions were to be used for patients at high risk of falls. The policy states on page 1 of 2 under low risk fall interventions: "d).....Employee to remain with patient while toileting."

2. Review of patient #1 medical record indicated the following:
(A) He/she was admitted on 2/27/17 with diagnoses including, but not limited to, Dementia with disturbance of behavior, Psychosis, and hypertension.
(B) Admission orders date 2/27/17 at 1712 hours included an order for fall precautions.
(C) Admission Nursing Assessment dated 2/27/17 with time of arrival listed as 1605 hours indicated the patient transferred with assist of 1 and wheelchair was checked under the ambulation section.
(D) Document titled "Edmonson Psychiatric Fall Risk Assessment" indicated that the patient had a score of 105 on 2/27/17 (high risk for fall = score of 90 or >). His/her score remained >90 throughout the stay.
(E) Braden scale pressure score risk document dated 2/27/17 indicated that the patients activity was a 2 which indicated he/she was chairfast and his/her ability to walk was severely limited or nonexistent.
(F) Activity assessment dated 2/27/17 indicated the patient ambulated with assistance.
(H) The medical record indicated that the patient had several falls during the hospital stay including:
a. On 3/3/17 at 1400 hours found on floor and plug was not plugged in appropriately to activate the bed alarm. No injuries noted.
b. On 3/4/17 at 2045 hours when an aide was assisting the patient to bed and his/her feet slipped and the patient was lowered to the floor. The record indicated that the patient had on non skid socks. No injuries noted.
c. On 3/5/17 at 0815 hours when patient got up unassisted. The nurse was close by and the patient reached for the nurse, however lost balance and fell. No injuries noted.
d. On 3/7/17 at 1610 hours when the patient was left unattended in the restroom and fell from the commode. The patient received a 1 inch laceration to the head.
e. The medical record lacked evidence what specific fall precaution interventions were in place or what additional measures were taken to prevent falls after each fall.

3. Staff member #1 (Chief Clinical Officer) indicated the following in interviews beginning at 4:30 p.m. on 4/20/17:
(A) He/she started at facility in January 2017 and realized there was a problem with falls. He/she rewrote the fall risk policy, however realizes that it still needs work and they are looking at it again.
(B) He/she indicated that staff education related to falls has been conducted, however was unable to provide information/evidence that the causes of the falls for patient #1 with actions taken had been addressed.

4. Staff member #2 (D.O.N.) indicated in interview at 4:45 p.m. on 4/20/17 that he/she now reviews all incident reports at this time and has been instructed that he/she needs to follow-up with staff on concerns identified with the review of the reports.

5. Review of document titled "STAFF MEETING AGENDA" dated 3/10/17 indicated that falls were addressed, however the document lacked evidence that causes of falls related to patient #1 (i.e. alarm/bed unplugged, patient up unassisted, and patient left in restroom unattended) were addressed.