HospitalInspections.org

Based on observation, interview, record review, document review and policy review, the hospital failed to ensure an organized nursing service to supervise, assess, and evaluate care for each patient regarding prevention of falls for four of four patients (Patients 1, 2, 3, and 4). Failure of the hospital to ensure patient falls are prevented has the potential for all patients to experience, harm, injury and death.

Findings Include:


1. Review of the hospital's policy titled, "Fall Prevention Program," dated 12/02/20 showed the fall prevention program is designed to reduce the risk of falls at the hospital with particular emphasis on patient related falls ...a fall is defined as an unintentional change in position coming to rest on the ground, floor or onto the next lower surface ...the evidence based risk screening tool used is the Morse Fall Risk Scale ...frequency of assessment/reassessment ...on admission ...on transfer from one unit to another within the hospital ...following any change of status ...following a fall ...weekly minimum ...an RN will determine an initial level (basic or high) based on clinical judgement, hospital determined scoring levels, and other assessments ...Morse Fall Score 46-94 = BASIC RISK, yellow patient wrist band ...yellow magnet on patient room door ...Morse Fall Score > or = 95 is HIGH RISK, orange patient wrist band ...orange magnet on patient room door.

2. Review of the Agency for Healthcare Research and Quality (AHRQ) site (www.ahrq.gov) showed Morse Fall Scale, 0 - No risk, < 25 - Low risk, 25-45 Moderate risk, and >45 High risk.

3. Review of the hospital's report titled, "Fall Risk: Current Score (Morse)," dated 09/30/21 showed a current census of 59 patients. The column titled "risk" showed 39/59 patient scored "high". The scale at the bottom of the report showed HIGH RISK = 46 points or higher. This score at the bottom of the sheet accurately reflected the score of the standardized Morse Scale.

4. Review of the hospital's undated document titled, "2021 Annual Competency Blitz," showed interventions for patients at a higher fall risk ...never leave them alone in the bathroom, stay within arm's reach of the patient ...there are patients that are at higher risk for falls than others ...brain injuries and strokes.

5. Observation on 09/30/21 at 8:03 AM, this surveyor walked through the east, west and south mods to assess if any rooms had falls magnets outside the doors and there failed to be any rooms with fall magnets per policy to alert staff of a patient's fall risk.

6. During an interview on 09/28/21 at 3:03 PM, Staff B, Director of Quality and Risk (DQR) stated that they treat all patients as being a fall risk.

7. During an interview on 09/30/21 at 8:34 AM, Staff B, Director of Quality and Risk (DQR) clarified each patient room should have a star magnet indicating they are a fall risk.

8. During an interview on 09/29/21 at 7:32 AM, Staff V, Rehab Tech, stated that about 85-90 % of the patients are a fall risk, she could not remember having any high risk fall patients, but if they did a third bed rail would be up while in bed, they would use the same bed and chair alarms, and they would have two people if needed for patient care.



9. Review of Patient 1's discharged medical record on 09/29/21, showed Patient 1, a 60-year-old female, admitted on 08/17/21, with a diagnosis of a stroke with right sided weakness, Parkinson's disease (a disorder that affects movement, often including tremors), early dementia (a group of thinking and social symptoms that interferes with daily functioning), bipolar (mood swings ranging from manic highs to depressive lows), and hypertension (high blood pressure).

a. Review of Morse fall risk score showed the risk level based on the hospital policy/as compared to the risk level based on the standardized Morse Fall score:

On 08/17/21 a score of 20 (no risk)/ (low risk)

This medical record showed the patient was assessed as "no risk" on admission according to the hospital's policy but should have been a "low risk" according to the standardized Morse fall scale.

b. Review of PT evaluation dated 08/18/21 at 10:00 AM, Staff Q, Physical Therapist (PT) noted toilet before high risk fall medication, and toilet before leaving room.

c. Review of OT evaluation dated 08/18/21 at 9:00 AM, Staff P, Occupational Therapist (OT) noted toilet before high risk fall medication, and toilet hygiene dependent.

d. Review of post fall assessment dated 08/19/21 at 11:49 AM, Staff DD, RN showed the patient (Patient 1) had an unwitnessed fall in her room on 08/19/21 at 10:35 AM when she fell out of her wheelchair attempting to transfer herself back to bed, and she had a skin tear to her right lower extremity.

e. Review of the form titled, "Compose Apologize Listen Make it Right (CALM)" dated 08/19/21 showed Staff N, RN Supervisor completed the verbal complaint that showed the patient had been brought back by therapy and was sitting alone in her room in her wheelchair. Staff J, MD had assessed the patient and when the doctor left, Patient 1 tried to get up out of the wheelchair and fell which resulted in a skin tear on the right lower leg.

f. Review of Morse fall risk score showed the risk level based on the hospital policy/as compared to the risk level based on the standardized Morse Fall score:

On 08/19/21 a score of 75 (basic risk)/ (high risk)

According to the hospital's fall scale the patient was changed to a "basic risk" after her fall on 08/19/21 and she should have been a "high risk" according to the standardized Morse Scale.

g. Review of an email dated 08/24/21 showed Staff N, RN Supervisor brought down signs that were posted in the patient's room. One of the signs showed please return patient to nurse's station after therapy, patient must be supervised at nursing station or in bed at this time; and the third showed ...must be supervised.

h. Review of an email dated 08/25/21 showed we just watched a video...therapy tech (Staff W) took patient back to room at 8:44 AM, left the room at 8:47 AM ...at 9:07 AM therapist went into the room, followed by an RN ...nursing supervisor ...the only other person who entered the room between 8:47 AM and 9:07 AM was a therapy tech who entered the room at 8:51 AM and came out immediately with a Hoyer lift. (The video was no longer available as they only keep them for 30 days).

i. During an interview 09/29/21 at 8:16 AM, Staff P, OT, stated that she uses the fall assessment and her clinic judgement to see the whole picture. Staff P remembers patient 1 had a fall after breakfast and the team knew she was a fall risk, she can be with family and at the nursing station to ensure safety. Staff P stated that a rehab tech took the patient to her room after breakfast in the therapy room, and she is not sure if the tech knew to not leave her alone. Patient 1 fell in her room. Staff P remembers the patient had a stroke, poor cognition, her husband was present a good portion of the time and when he was not here we kept her at the nurse's station. Staff P stated that the patient would tell staff she would use the call light, but her responses were inconsistent cognitively and she had no safety awareness.

j. During an interview on 09/29/21 at 10:42 AM, Staff X, Speech Therapist (ST), stated that at the evaluation for Patient 1, she was low level, cognitive dependent, she could understand one step commands sometimes, she answered 80% on simple yes, no questions, 40% accuracy with one step instructions, she could name objects from pictures, count 1-10 and say the days of the week. Staff X stated that the morning of 08/19/21 she fed Patient 1 her breakfast from 8:00 AM to 9:00 AM in the therapy room, and when she was through Staff W, a therapy tech took her back to her room. Staff X stated that about 9:30 AM she went to the patient's room and the tech told her about the fall. Staff X put up lots of signs in the room after she found out she fell. Staff X stated that every patient is a fall risk so it's not a huge red flag, but Patient 1 did not move when she was in her wheelchair, so it was very surprising she fell. Staff X stated that her signs she made were very specific that Patient 1 not be left alone, and she must be at nursing desk.

k. During an interview/phone call on 09/29/21 at 12:07 PM, Staff W, therapy tech, stated that she took Patient 1 back to her room, sat her by the table and left her. Staff W stated that another tech came to her and said to her that she is not to leave the patient alone next time. Staff W stated that speech therapy posted the instructions after she left the room.

l. Nursing staff failed to supervise Patient 1 appropriately and left her alone in her room sitting in a wheelchair with no supervision. This led to Patient 1 trying to get up on her own and falling.



10. Review of Patient 2's discharged medical record on 09/29/21, showed Patient 2, an 80-year-old female, with a diagnosis of falls, skin cancer, orthostatic syncope (loss of consciousness due to reduced blood flow to the brain), diastolic hypotension (low blood pressure), and atrial fibrillation (an irregular rapid heart rate that causes poor blood flow) was admitted on 04/07/21.

a. Review of Morse fall risk scores showed the risk level based on the hospital policy/as compared to the risk level based on the standardized Morse Fall score:

On 04/07/21 a score of 65 (basic risk)/ (high risk)
On 04/13/21 a score of 65 (basic risk)/ (high risk)
On 04/15/21 a score of 65 (basic risk)/ (high risk)

This medical record showed the patient was assessed as "basic risk" according to the hospital's policy but should have been a "high risk" according to the standardized Morse fall scale.

b. Review of PT evaluation dated 04/08/21 at 9:00 AM, Staff EE, PT noted toilet before high risk fall medication, toilet before leaving room, and fall precautions.

c. Review of OT evaluation dated 04/08/21 at 7:30 AM, Staff FF, OT noted toilet before high risk fall medication, toilet hygiene dependent, and fall precautions.

d. Review of post fall assessment dated 04/15/21 at 11:40 PM, Staff T, RN noted the patient walked to the bathroom with stand by assist and a walker, the fall occurred 04/15/21 at 9:50 PM in the patient bathroom. The fall was witnessed, but not intercepted. The patient soiled her pajamas, she had more loose stools while sitting on the toilet, the nurse went to get a clean brief, insert and pajama bottom from the closet when she heard the patient fall to the floor. The patient responded to her name only for a couple of minutes, vital signs were assessed, the patient was transferred to the bed and she responded appropriately after she transferred to the wheelchair. Skin care was provided for bruising to the right knee, the physician was notified with orders to send the patient to the hospital for an evaluation. The patient had aching pain rated 6/10 to the right side of her head, she was alert and appropriate, she had bruising to her right knee, right elbow, a laceration to the right scalp, traumatic injury to the nose and forehead. Blood pressure at 10:17 PM was 73/51, pulse 82.

f. This medical record showed the patient was a "basic risk" upon admission and after the falls was a high risk according to the standardized Morse fall scale. According to the hospital's fall scale the patient remained a basic risk until her discharge to another facility, even though she fell and that should have made her a high risk.

g. During an interview/phone call on 09/29/21 at 12:41 PM, Staff Z, RN supervisor stated that
she was told Patient 2 had been on the toilet, the nurse turned around to get something, Patient 2 fell, they got her into bed, and they called 911. Staff Z stated that Patient 2 had a gash on her head and nose lacerations. Staff Z stated that she later called the receiving hospital to get an update and she was told the patient had some heart issues going on, she may have had a heart event on the toilet and they are not sure.

h. During an interview on 09/29/21 at 6:48 PM, Staff T, RN stated that she had given Patient 2 a suppository, took her to the toilet a little time later with her walker, she took her pants down that were soiled, she stepped around the door to the patient's closet in her room to get some clean pajamas and she heard a "clunk." She ran into the bathroom, saw she was on the floor, called for help, assessed her as she was mumbling at first, they go the patient back into bed, then she was more responsive. Staff T stated the signs in the room stated to not leave the patient alone.

i. Nursing staff failed to remain with the patient while she was toileting, and the patient fell requiring a trip to the emergency department.



11. Review of Patient 3's discharged medical record on 09/29/21, showed Patient 3, a 73-year-old female, admitted on 01/16/21, with a diagnosis of a stroke with left weakness, hypertension, osteoarthritis (flexible tissue at the ends of the bones wear down), chronic obstructive pulmonary disease (COPD - lung diseases that block airflow and make it difficult to breath), and osteoporosis (when bones become weak and brittle).

a. Review of Morse fall risk scores showed the risk level based on the hospital policy/as compared to the risk level based on the standardized Morse Fall score:

On 01/16/21 a score of 65 (basic risk)/ (high risk)
On 01/19/21 a score of 60 (basic risk)/ (high risk)
On 01/21/21 a score of 80 (basic risk)/ (high risk)

This medical record showed the patient was a "basic risk" upon admission. According to the hospital's fall scale the patient was assessed as a basic risk, but should have been a "high risk" according to the Morse Fall Score.

b. Review of PT evaluation dated 01/18/21 at 2:00 PM, Staff EE, PT noted toilet before high risk fall medication, toilet before leaving room, and fall precautions.

c. Review of OT evaluation dated 01/18/21 at 9:30 AM, Staff GG, OT noted toilet before high risk fall medication, toilet hygiene dependent, and fall precautions.

d. Review of the report dated 01/21/21 at 12:00 AM for Patient 3 showed she was assisted to the bathroom ...using her walker ...rehabilitating for fracture pelvis ...patient was left on the toilet with call light ...nurse stepped away for a pillow case ...patient did not use call light when finished but attempted to stand ...reported getting tangled up in her pajama pants and falling ...no visible injury ...pain to left shoulder persisted ...x-ray at 1:10 AM and was placed in immobilizer for left humeral fracture.

e. Review of post fall assessment dated 01/21/21 at 12:41 AM, Staff T, RN noted the patient the patient put on her call light and was assisted to the bathroom, the nurse went to get a pillow case, and when she returned the patient was on the floor on her left side. The patient had a bruised, displaced left shoulder.

f. Nursing staff failed to remain with the patient while she was toileting, and the patient fell requiring an X-ray and leaving the patient with a dislocated shoulder.



12. Review of Patient 4's discharged medical record on 09/29/21, showed Patient 4, a 69-year-old female, admitted on 05/06/21, with a diagnosis of mobility deficits, critical myopathy, hypertension, COPD, stroke, osteoarthritis, anxiety, and alcoholic use disorder was admitted on 05/06/21.

a. Review of Morse fall risk scores showed the risk level based on the hospital policy/as compared to the risk level based on the standardized Morse Fall score:

On 05/06/21 a score of 50 (basic risk)/ (high risk)
On 05/11/21 a score of 65 (basic risk)/ (high risk)
On 05/18/21 a score of 35 (not a risk)/ (moderate risk)
On 05/25/21 a score of 65 (basic risk)/ (high risk)

This medical record showed the patient was assessed as "basic risk" on admission according to the hospital's policy but should have been a "high risk" according to the standardized Morse fall scale.

b. Review of PT evaluation dated 05/07/21 at 1:00 PM, Staff BB, PT noted toilet before high risk fall medication, toilet before leaving room, and fall precautions.

c. Review of OT evaluation dated 05/07/21 at 9:00 AM, Kim Staff HH, OT noted toilet before high risk fall medication, toilet hygiene dependent, and fall precautions.

d. Review of the report dated 05/19/21 at 2:00 PM for Patient 4 showed Staff R, PT told patient to stay in chair for a moment while she found the next therapist to see where they wanted her to be for the next session, patient agreed, but confirmed that PT would be right back ...PT came back in about one minute later to find patient on the floor on her right hip with the chair alarm going off ...patient reported that she had hit her head on the wheelchair and landed on her right hip pretty badly...patient was Hoyer lifted to her bed ...fracture to right 10th rib fracture, abrasion/bruise/contusion, head injury, pain, swelling/inflammation, physician notified for diagnostic testing.

e. Review of post fall assessment dated 05/19/21 at 2:32 PM, Staff U, RN noted the patient had an unwitnessed fall. The patient was alert and oriented, she had a right hip pain rated at 8/10, and described as tender and constant, a hematoma to her right flank (on your back between your lower ribs and hips), and a mass felt on her right hip.

f. Staff R, PT remembers Patient 4 could stand unsupported for five seconds, and she had some stability. Staff R explained at the end of her session with the patient, she needed to find the next therapist, she made sure the chair alarm was on, she was in her room, she had her call light in her hand, and during the 30 seconds I was gone she fell. Staff R stated that they called team star (our way to communicate with the whole staff to evaluate the situation), and Staff BB another PT, took over.

h. Staff BB, PT described Patient 4 as more confused and unsafe on some days than others. Staff BB stated the day Patient 4 fell a staff member came to get her and she came in and saw patient on floor with the team star personnel present. Staff BB heard, the patient tried to get up on her own from the wheel chair with PT present and fell. Patient 4 was on the floor when she arrived, nursing was doing their assessment, we did a floor transfer, verbal cues were given to patient throughout the transfer, and she needed a lot of help to get up. Staff BB remembers Patient 4 had pain on her right side, a stat x-ray was done to her hip to rule out a fracture, and the x-ray came back negative (no fracture).

k. During an interview on 09/29/21 at 11:25 AM, Staff U, RN stated that nurses complete the Morse fall assessment on each patient at admission, weekly and if a fall occurs. Staff U stated that after a fall they do a post fall assessment and complete a report. Staff U explained a yellow wrist band is for a fall score over 45, they have alarms for chair and beds. Staff U stated that a high risk fall category is for a score over 95, they have orange wrist bands, they have low beds, mats, more things posted in the rooms, and they cannot refuse any alarms. Staff U remembers he performed the post fall assessment for Patient 4 who was found by therapy next to her wheelchair after a therapist left her alone and she tried to get up. Patient 4 had pain to her right flank, hip and head. Staff U stated that there was no deformity to skin on the head, there was a new contusion to right flank, and the patient had grimacing when hip was flexed. Staff U stated that a bilateral hip x-ray was performed stat, and Patient 4's family member was notified of the incident. Staff U confirmed the bed alarm and call light was working.

l. Nursing staff failed to accurately score the patient on the Morse Fall Scale, falsely showing the patient as a low fall risk when she should have been considered a high fall risk. Hospital staff left the patient alone while toileting and the patient fell. Nursing staff failed to conduct an updated Morse Fall Score after the patient sustained the fall.