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Based on medical record review, policy and procedure review and staff interview it was determined the facility failed to accurately evaluate and follow hospital policy for three sampled patients in the area of fall assessments. ( Patient #'s 2, 13, and 12). Closed records for Patient #4 and #15 revealed the facility failed to notify the physician of the falls as required by policy. Nine closed records were chosen of 18 patients who had fallen in the facility's during the 2012 reporting period. The patient census is 47.

Findings include:

Patient #2 medical record was reviewed on 08/08/12 and 08/09/12. This patient sustained two falls while hospitalized from 01/25/12 to 02/06/12. Fall number one occurred on 01/29/12 and fall number two occurred on 02/04/12. The 80 year old patient was admitted to the hospital with nausea, vomiting, complaint of abdominal pain, history of colon cancer, and was receiving chemotherapy.

The initial nursing assessment using the Morse Falls Risk Assessment completed on 01/26/12 identified the patient at Score of "30" Low Falls Risk. On 01/27/12, 01/28/12, and 01/29/12 the patient was assessed at "30" (low fall risk). On 01/29/12 at 2:05 PM patient #2 stood in the bathroom, lost his balance and fell into the bedside commode. The patient had staff assistance at the time of the fall. Patient #2 was assessed at "85" High Falls Risk from 01/30/12 through discharge on 02/06/12. The interventions used for falls prevention included patient identification for high falls risk with colored arm band etc, bed maintained in low position, call light with-in reach, two of the four side rails in up position, bed alarm, and "up" with assistance only. The patient received non displaced fractures of the ninth and tenth ribs on the right side. Patient #2 received a physical therapy (PT) evaluation on 01/31/12 and an occupational therapy (OT) evaluation on 02/01/12. On 02/02/12 the PT progress note stated "Continue to recommend 24 hour skilled assist upon discharge secondary to impulsivity, poor safety awareness and near scissoring gait pattern." The patient was also assessed as having periods of confusion during his hospital stay. On 02/04/12 at 4:30 AM patient #2 was assisted to the bathroom. The staff member left the patients side to change the bed pad. Patient #2 "attempted to stand up and fell backwards onto the bed pan cleaning arm (of the toilet) resulting in a 10 cm by 4 cm abrasion with small amount of bleeding from the bottom edge- mid back right side."

Review of the hospital Fall Prevention Program policy and procedure revealed that patients determined to be High Falls Risk "will not be left unattended while toileting, e.g., bathroom, bedside commode, urinal etc." This was confirmed by staff E on 08/08/12 at noon.

Review of the medical record for patient # 13 on 8/08/12 revealed the patient was admitted to the facility on 8/07/12 with a diagnosis of Right hip fracture, Osteoporosis and Generalized Arthritis. The fall assessments completed at each shift by the nursing staff had revealed the patient was considered as meeting the risk criteria for a person at high risk for falls. The fall assessment trigger questions on each fall assessment for all patients asked the questions as follows:
History of falls, secondary diagnosis, ambulation, intravenous therapy, gait and mental status. Each section was marked with the points this section counted. The total points determined the degree of the patient's fall risk. This patient had a total score of 55. The combination of points that were above 50 points made the patient a high fall risk patient. Further review of patient #13's medical record revealed the fall assessment dated 8/07/12 did not give points to the section of the patient's secondary diagnosis. The patient's secondary diagnoses were Osteoporosis, Coronary Artery Disease and Hypertension. Without the points counted for the medication risk component added, the patient would not have been at a high fall risk.

Review of the medical record for patient #12 on 8/09/12 revealed this patient was admitted to the facility on 8/05/12 with a diagnosis of Acute Pneumonia with a secondary diagnosis of Seizures and Profound Mental Retardation. The fall assessment completed on 8/08/12 revealed a high risk score based on the patient having intravenous therapy, impaired gait and impaired mental status. There were no points added for the patient's secondary diagnosis.

Review of the facility's policy "Fall Prevention Program" effective March 2005 last revised on February 2010 revealed no direction for staff to determine the secondary diagnosis that would be applicable for the point scoring system in the fall risk assessment.

Review of the closed medical record of patient #4 on 8/07/12 revealed this patient fell at the facility on 3/22/12 at 1:30 AM. There was no evidence this patient's physician was notified of the patient's fall at that time. The physician did come to see the patient on 3/22/12 at 2:40 PM although there was no evidence the physician was made aware of the patients fall earlier that day. This finding was confirmed on 8/07/12 at 9:15 PM by Staff D who revealed the doctor should have been notified of the patient's fall.

Review of the closed medical record of patient #15 on 8/08/12 revealed this patient had fallen at the facility on 4/20/12 at 5:15 AM. There was no evidence the 82 year old patient's family was notified of this fall. The patient had sustained a 3 centimeter by 2 centimeter bruise as a result of the fall. Interview of staff E on 8/08/12 at 11:55 AM confirmed there was no evidence the patient's family was notified of this fall.

Review of the facility's policy "Fall Prevention Program" effective March 2005 last revised on February 2010 revealed in the event of a patient fall, the patient's physician should be notified.




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This substantiates Complaint Number OH00064333.

Based on observation and staff interview the facility failed to ensure boxes were stored off the floor in order to maintain a safe hospital environment. The facility census was 47.

Findings included:

During tour of the facility with Staff A on 8/07/12 from 10:20 AM to 11:34 AM observations were noted by surveyor and Staff A of the following:

The laboratory had seven cardboard boxes stored on the floor of areas of three rooms of the laboratory.

The medical records department had a row of empty cardboard boxes for packing records stored on the floor.

The emergency room had four boxes of copy paper with two of the boxes stored on the floor.

A storage area identified by staff A as the "old CT room" had five cardboard boxes stored on the floor.

The area outside the Magnetic Resonance Room had three boxes stored on the floor.

The pharmacy had eight cardboard boxes stored on the floor.