HospitalInspections.org

Based on observation, interview, and record review, the facility failed to fully analyze an adverse patient event and implement timely preventative actions (citing Patient # 1).

Patient # 1 fell on 04-15-19 and sustained an injury. As of 04-22-19, the patient's fall was not fully analyzed & no additional fall prevention measures had been implemented.

Findings included:

TX 00312429

Review of facility's policy titled "Occurrence Reporting," dated 09/16, showed definition of "Adverse Event": an event that results in unintended harm to a patient by an act of omission rather than the underlying condition of the patient. The policy further stated the department manager was to document factors that contributed to the occurrence (such as human factors, process deficiencies, other factors, etc. ).

Review of Patient # 1's medical record showed documentation left thumb had discoloration and edema post-fall on 04-15-19... diagnosed with non-displaced fracture of the left thumb; splint applied on 4-16-19 (time 15:44).

Observation on 04-22-19 at 10:15 AM showed Patient # 1 laying in bed with family members in room.

During an interview at this same time with a family member, she stated Patient # 1 fell from his wheelchair over a week ago. The patient was a bilateral amputee and wheelchair bound. On the day Patient # 1 fell, his sister received a telephone call from the nurse who told her patient had just finished physical therapy and he was left unattended in his wheelchair. "Patient # 1 was strapped into the chair bur still managed to fall." Family member went on to say they were later told the patient took the belt off and then fell.

She said family had requested Patient #1 not be left by himself, as he had dementia. She went on to say the facility had not done anything differently to prevent future falls for Patient #1. When asked, family said there was no chair alarm for the the wheelchair. Observation failed to show an alarm in the wheelchair.

Record review of facility Incident Report, dated 04-15-19 (time 1710), showed documentation of an unwitnessed fall in room 135. Certified nurse aide (CNA) found patient ( # 1) on the floor on his right side. Nurse assessed patient ; he was assisted back to bed. Patient # 1 sustained minor skin tears to right and left hand and left upper arm; wounds were cleaned & dressed. CT of head ordered.

Further review of the Incident Report Form, dated 04-15-19 showed a section titled " SUGGESTIONS FOR FUTURE PREVENTION OF THIS TYPE OF OCCURRENCE." This section was left blank.

During an interview on 04-22-19 at 3:30 PM with Staff C , Quality Resource Manager, she stated she had not yet fully investigated Patient # 1's fall. She did not know if staffing; staff training; communication; patient medications; or inadequate fall prevention measures may have contributed to Patient # 1's fall.

During an interview on 04-22-19 at 3:00 PM with Staff B , Chief Nursing Officer (CNO) she stated Patient # 1, as a recent bilateral amputee, was clearly a high risk for falls. He should have had a chair alarm in place at the time of the fall. She was unsure if Patient # 1 had a chair alarm at present.

Based on observation, interview, and record review, a registered nurse failed to supervise and evaluate the care for 4 of 4 sampled patients ( Patient ID# 1,2, 3, 4,) .

a. Neurological assessments were not conducted according to established facility process for Patient # 1 after he sustained a fall;

b. Facility policy; fall risk assessment documentation; and staff understanding of fall risk assessment & prevention were not consistent (as related to 4 sampled patients at risk for falls).

Findings included:

Neurological Assessments : Patient # 1 :

Record review of facility Incident Report, dated 04-15-19 (time 1710), showed documentation of an unwitnessed fall in room 135. Certified nurse aide (CNA) found Patient ( # 1) on the floor on his right side. Nurse assessed patient ; he was assisted back to bed. Patient # 1 sustained minor skin tears to right and left hand and left upper arm; wounds were cleaned & dressed. CT of head ordered.

Record review of form titled "Post-Fall Management," dated 4-15-19, for Patient # 1 showed : Neuro checks were performed on 04-15-19 at 1710 per facility established ( Glasgow Coma Scale: pupillary reactivity; motor & verbal responses; level of consciousness,etc..).

Further review of this same form read: "...7 a. For the 48 hours following the fall: obtain vital signs and neuro checks every two(2) for the first 12 hours and every four hours for the next 36 hours...."

Patient # 1's medical record was reviewed with Staff B, CNO (Chief Nursing Officer). CNO was unable to locate & verify that nursing obtained vital signs and conducted neuro checks per established facility process for Patient # 1 for the 48 hours post-fall.

Fall Risk: assessment & interventions: inconsistencies:

Record review of facility policy titled "Fall/Safety Assessment," dated 6/2016 showed a Registered Nurse (RN) would assess a patient within 8 hours of admission and reassess every 24 hours for fall risk. Fall risk determination was made based on age, physical impairment, history of falls, etc...Total risk assessment scores determined the risk level : normal, moderate, high, and extremely high risk ( Levels 1 through 4). Each level had specific fall risk interventions specified for that level. The levels identified in the facility policy were as follows:

Level I : 0-6 points : normal risk
Level II : 7-14 points : moderate risk
Level III : 14 + points: high risk
Level IV: ( no point value given ) : extremely high risk

During an an interview on 04-22-19 at 1:30 PM with Staff B, Chief Nursing Officer (CNO) , she stated if a patient was assessed as high risk for falls, nursing should implement the following interventions: bed in low position; bed alarm activated, call light in reach; and if in wheelchair (W/C) : chair alarm in place. CNO also said patients assessed as fall risk at all levels should have a yellow fall risk band placed on their wrist.

On 04-22-19 at 9:45 AM patient census was reviewed with charge nurse. Four (4) patients were identified by Staff D, RN Charge Nurse, as high risk for falls: Patient # 1, 2, 3, & 4.

On 04-22-19 between 9:45 AM and 11 AM, observation, interview, and record review of each of these 4 patients was conducted.

Patient # 1:

Observation on 04-22-19 showed Patient # 1 bed; he had bilateral amputation of lower extremities ( left side 3/22/19) ; wheelchair in room; family at bedside. Family stated patient fell from his W/C in the facility about a week ago. Family member said the patient did not currently or ever have a chair alarm; no yellow fall risk ID band was observed on the patient.

Patient # 2:

Observation on 04-22-19 showed Patient # 2 laying in bed; awake, alert & oriented. During an interview with Patient # 2 said she had a history of falling at home; she had recently broken a rib.

Further observation showed the bed was not in low position; patient was not wearing a yellow fall risk ID band.

Record review with the CNO on 04-22-19 of Patient # 2's electronic medical record (EMR) it showed she was admitted on 04-17-19. Initial nursing assessment, dated 04-17-19, showed "Fall Risk : HIGH: 45 or higher." [ facility fall policy did not address a fall risk point value of 45 ].

Further review failed to show completed fall risk assessments per shift for 4-18-19; 04-20-19; and 4-21-19.

Patient # 3:

Observation on 04-22-19 showed Patient # 3 sitting in a chair; adult daughter in room. During an interview with Patient #3's daughter, she said her mother had fallen at home on 4-03-19 ; she used a walker to ambulate.

Record review with the CNO on 04-22-19 of Patient # 3's electronic medical record (EMR) it showed she was admitted to observation on 04-11-19. Initial inpatient nursing assessment, dated 04-13-19, showed "Fall Risk : HIGH: 45 or higher." On 04-14-19, nursing documented Patient # 3's fall risk as "Moderate 25-44". [ current facility fall policy did not address a fall risk point value of 45 ; current policy stated moderate risk was 7 to 14 points]

Further observation showed Patient # 3 was not wearing a yellow fall risk ID band.

Patient # 4:

Observation on 04-22-19 showed Patient # 4 laying in bed; awake, alert & oriented. Daughter at bedside sitting in chair.

Record review with the CNO on 04-22-19 of Patient # 4's electronic medical record (EMR) it showed she was admitted on 04-18-19. Initial inpatient nursing assessment, dated 04-18-19, showed "lower extremity weakness; gait unsteady, uses a rollator to ambulate." Unable to locate a numerical fall risk assigned.

Review of daily nursing assessment for Patient # 4 it showed a column in the EMR : "History of Falling with "25" written here; under Fall Risk, it read "MOD." Interview at this time with CNO, she stated she did not know what the "25" meant. CNO further stated the entries in the EMR related to fall risk were not consistent with the facility's current Fall Assessment policy.

Based on observation, interview, and record review, the facility failed to ensure a nursing care plan was developed that addressed patient's assessed needs for 4 of 4 current sampled patients (Patient ID # 1, 2, 3, 4 ).

Findings included :

Record review of facility policy titled "Interdisciplinary Care Plan," dated 9/2016, showed care planning addressed needs resulting from patient's condition...individual care and treatment goals were identified to "reflect patient's unique needs."


On 04-22-19 at 9:45 AM patient census was reviewed with charge nurse. Four (4) patients were identified by Staff D, RN Charge Nurse, as high risk for falls: Patient # 1, 2, 3, & 4.

On 04-22-19 between 9:45 AM and 11 AM, observation, interview, and record review of each of these 4 patients was conducted.

Patient # 1:

Observation on 04-22-19 showed Patient # 1 bed; he had bilateral amputation of lower extremities (left side 3/22/19) ; wheelchair in room; family at bedside. Family stated patient fell from his W/C in the facility about a week ago.

Record review with the CNO on 04-22-19 of Patient # 1's electronic medical record (EMR) it showed he was admitted to a swing bed on 03-28-19. Further review of his record showed:

04-03-19 : x-ray showed pneumonia; equalizer treatments given;

04-06-19: unit of packed red blood cells infused;

04-08-19: patient wheezing; neb treatment; oxygen at 2 liters

Continued review of Patient # 1's EMR, specifically the Care Plan, with the CNO failed to show specific nursing interventions related to fall prevention, respiratory issues, infection , blood infusion, or oxygen administration.

Patient # 2:

Observation on 04-22-19 showed Patient # 2 laying in bed; awake, alert & oriented. During an interview with Patient # 2 said she had a history of falling at home; she had recently broken a rib.

Record review with the CNO on 04-22-19 of Patient # 2's electronic medical record (EMR) it showed she was admitted on 04-17-19. Further review of her record showed:

a. history of falling; chronic foot drop;
b. she had an indwelling urinary catheter;
c. she received insulin per sliding scale;
d. intractable pain

Continued review of Patient # 2's EMR, specifically the Care Plan, with the CNO failed to show specific nursing interventions related to fall prevention, pain, indwelling catheter, insulin/blood sugar, and pain.

Patient # 3:

Observation on 04-22-19 showed Patient # 3 sitting in a chair; adult daughter in room. During an interview with Patient #3's daughter, she said her mother had fallen at home on 4-03-19 ; she used a walker to ambulate.

Record review with the CNO on 04-22-19 of Patient # 3's electronic medical record (EMR) it showed she was admitted to observation on 04-11-19. Initial inpatient nursing assessment, dated 04-13-19, showed "Fall Risk : HIGH: 45 or higher." On 04-14-19, nursing documented Patient # 3's fall risk as "Moderate 25-44".

Further observation showed Patient # 3 was not wearing a yellow fall risk ID band.

Continued review of Patient # 2's EMR, specifically the Care Plan, with the CNO failed to show specific nursing interventions related to fall prevention.

Patient # 4:

Observation on 04-22-19 showed Patient # 4 laying in bed; awake, alert & oriented. Daughter at bedside sitting in chair.

Record review with the CNO on 04-22-19 of Patient # 4's electronic medical record (EMR) it showed she was admitted on 04-18-19. Initial inpatient nursing assessment, dated 04-18-19, showed "lower extremity weakness; gait unsteady, uses a rollator to ambulate." Continued record review showed :

04-18-19: wheezing & crackles upper lobes; shortness of breath; edema noted to all 4 extremities; 3+ edema to lower extremities; equalizer treatments & IV lasix administered; Foley catheter.

04-19-19: arterial Doppler study ordered for bilateral legs: bluish; coloration; very cold to touch.

Continued review of Patient # 4's EMR, specifically the Care Plan, with the CNO failed to show specific nursing interventions related to specific respiratory and circulatory issues and fall prevention.