HospitalInspections.org

Based on record review and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care to ensure patient needs were met for fall precautions for one (#5) of 10 sampled patients.

Findings included:

Patient #5 was admitted on 5/23/17 as a transfer from an acute care hospital.

The Admission Nursing Assessment dated 5/23/17 indicated Patient #5 was alert, but not verbally responsive. The Glasgow Coma Score was 10/15 indicating neurological impairment. The patient was unable to follow simple commands. The nursing assessment dated 6/30/17 indicated Patient #5 was alert, anxious and uncooperative. At 8:00 p.m. the nursing documentation stated "Patient cannot comprehend fall risk instruction".

On 7/2/17 at 2:02 a.m. the assessment noted Patient #5 was alert, restless and impulsive. The Change of Condition note dated 7/2/17 and signed by the Licensed Practical Nurse indicated Patient #5 was found on the floor between the foot of the bed and the bathroom door at 12:28 p.m.

The review of Change of Condition documentation revealed Patient #5 had fallen on 6/7/17, 6/13/17, 6/16/17, 6/22/17, 6/23/17, 6/28/17 and 7/1/17 before falling again on 7/2/17 and sustaining a fractured hip.

An interview was conducted with the Chief Clinical Officer (CCO) on 8/16/17 at 11:45 a.m. She indicated on 7/2/17 Patient #5 was being attended by a sitter who was also responsible for a patient in an adjoining room. She indicated the facility practice at the time was to position a sitter immediately outside the adjacent doorways of two patients, where both patients could be in line-of-sight of one sitter. She indicated Patient #5 fell on 7/2/17 when the sitter went to check on the patient in the other room. She confirmed the finding the facility failed to provide the care and services necessary to meet the needs of Patient #5 to prevent a fall.