HospitalInspections.org

Based upon document review and interview, the facility failed to ensure all Registered Nurses followed the policies and procedures of the hospital for 2 of 10 medical records (MR) reviewed (Patient's #2 and #5).

Findings include:

1. Review of the policy/procedure Organizational Patient Assessment/Reassessment Plan (revised 12-19) indicated the following: "A medical history, a physical assessment, nursing care assessments and other screening assessments including fall risk...will be completed within 24 hours of admission for all inpatients by the Registered Nurse...The patient is reassessed...with changes in condition...The routine reassessment of the patient's status includes a system review every 8 hours for non-critical patients and every 4 hours for critical care patients. Reassessment will be documented."

2. Review of the policy/procedure Adult Inpatient Falls Prevention (revised 7-19) indicated the following: "Debriefing should occur as soon as possible after a fall occurs..." and identified the related document titled Post Fall Huddle Sheet as an attachment.

3. Review of the document titled Post Fall Huddle (no revision date) for Patient #2 indicated on 3-11-21 at 1740 hours the 9 North Surgical Unit Manager A9, the Medical Surgical Clinical Nurse Specialist A5 and the Registered Nurse N19 participated in the fall debriefing and indicated the following: "Complete steps 1-6 below... (5) Call patient's family to notify them of fall...All shifts notify family within an hour for injury regardless of time of day. (6)...reassess fall risk using the risk tool appropriate for (the) patient population..."

4. Review of the MR entry for Patient #2 by Registered Nurse N19 indicated on 3-11-21 at 1715 hours the patient was found on the floor with left forearm and posterior scalp injuries and no MR documentation indicated the patient's Healthcare Representative FM31 was notified of the patient's fall event within 1 (one) hour of the fall or indicated the patient's fall risk score was updated between 3-11-21 at 1600 hours (Morse Fall Risk Score = 85 [High Fall Risk >51]) until after transfer to the Intensive Care Unit on 3-11-21 at 2300 hours (Morse Fall Risk Score = 100).

5. On 3-30-21 at 0952 hours, the Clinical Nurse Quality Coordinator A3 confirmed the above and confirmed no other documentation was available.

6. The MR entry on 3-12-21 at 1153 hours by the Social Worker A10 indicated the staff met with FM31 while the patient was in the interventional radiology (IR) department for placement of a second chest drainage catheter. The entry by A10 indicated FM31 expressed concern about not being notified within the same day after the patient's fall.

7. Review of the MR entry for Patient #5 by Registered Nurse N14 indicated on 3-18-21 at 1715 hours the patient was found on the floor with a bump on their head and no MR documentation indicated the patient's fall risk score was updated after 3-18-21 at 1600 hours (Morse Fall Risk Score = 75 [High Fall Risk >51]) until Patient #5 was discharged to home on 3-19-21 at 1616 hours.

8. On 3-30-21 at 1510 hours, the Clinical Nurse Quality Coordinator A2 confirmed the above and confirmed no other documentation was available.