HospitalInspections.org

Based on review of hospital's policy, medical records, and interviews with staff, the facility failed to implement measures to prevent a fall for 1 of 2 sampled patients that had falls. (#5).

Findings included:

On 01/30/2018 review of the policy titled, "Fall prevention" revised February 03, 2017 revealed, "...All patients will be assessed for fall risk using an approved and validated risk assessment tool on admission" (Morse Fall Scale Risk Score) ..."All patients identified at moderate risk (25-45 score) to high risk (greater than 45 score) for falls will be placed on the Fall Risk Prevention and appropriate strategies incorporated." Review revealed the facility utilized several components to alert patients, visitors and staff to be mindful of patient safety, such as an educational fall prevention video, the use of "Visual Cues Bundle" (such as a yellow Fall Risk magnet outside the patient room at the door, yellow Fall Risk armband on the patient, the use of yellow non-slip socks on the patient and a sign for the patient and visitors in the patient room) for patients identified as moderate to high risk for falls. Review revealed documentation of staff education titled, "General Announcements...Huddle 12/15/2017 - 12/22/2017, DO safety check before you leave each room: F= are they a fall risk?, A= check alarm, AL= give call light, AL= bed low position. EVERYONE responds to bed/chair alarm like a code blue. ... Know your patient's MORSE Fall Score - >25 is a fall risk, -Use bed/chair alarm at all times. ..."

On 01/30/2018 closed medical record review revealed Patient #5 was a 94 year-old male admitted to the hospital on 11/28/2017- 12/08/2017, with history of irregular heart rhythm, and recurrent falls. On 12/02/2018 at 1900 the record revealed his documented Morse Fall Score of 85, as per policy patients with scores greater than 45 would be documented as a High Fall Risk. Further medical record revealed on 12/03/2017 at 0645 during his hospitalization, Patient #5 was found to have an unwitnessed fall, with last observed documented rounding at 0500 of his resting in the bed with the use of "adequate room lighting, bed in low position, bed/chair alarm in use, call device within reach, personal items within reach, safety rails in position for mobility, traffic path in room free of clutter, wheels locked". The record revealed an X-ray report on 12/03/2017 at 1715, Patient #5 sustained a "mildly displaced intertrochanteric fracture of the right femur". On 12/04/2017 at 1045 a Physician Progress Note for MD #1 revealed, Patient #5 had been "seen by ortho (consulted Orthopaedic Surgery on 12/03/2017 at 1616), family wants to proceed with surgery, however patient has developed afib with RVR (Rapid Ventricular Response: irregular often rapid heart rate that commonly causes poor blood flow with rapid ventricular rate which is fast contractions of the lower portion of the heart and the upper portion of the heart has difficulty keeping up with the fast contractions of the lower portion); will not be able to proceed with surgery today - evaluated by cardiology also, placed on Cardizem drip for rate control, started on IV (intravenous) hydration...". Record revealed the patient was then transferred to CCU (Critical Care Unit) for closer monitoring. On 12/06/2017 at 1230 Physician Progress Note of NP #1 of Palliative Care revealed, "...explained given age, prior debility, resistant UTI (urinary tract infection), pulmonary edema patient may have poor outcome. ... (family member) voiced desires to go with comfort directed approach and Hospice care and agreed to dc (discontinue) any life prolonging measures including antibiotics. Empathetic listening and active support provided. ... no surgery and comfort directed care."

On 01/30/2018 at 0930 an interview with ADM (Administrative Staff) #1 revealed, the events leading to Patient #5's fall on 12/03/2017. ADM #1 revealed, "He had a bath around 0430 and the staff members thought that they placed the bed alarm on, but it was not sounding when he was found to have fallen. It appears as though they thought the alarm was activated but it was not. We cannot find evidence that the bed alarm was activated after the patient's bath."

On 01/30/2018 at 1410 an interview with RN (Registered Nurse) #2 revealed, she recalled caring for Patient #5 at the time of the fall and was aware of the use of yellow magnet on his door, non-skid yellow socks, yellow fall precaution bracelet and the need for the bed alarm. The interview with RN #2 revealed that Patient #5 had a bed bath around 0430 after which the CNA (Certified Nurse Assistant) thought the bed alarm was reactivated in the "On position", however it was not reactivated. The failure to activate the bed alarm resulted in Patient #5 sustaining an unwitnessed fall. Interview revealed the bed alarm should have been reactivated when the bed bath was completed; however, the CNA failed to follow hospital policy.

Interview on 01/30/2018 at 1410 revealed RN #3 (charge nurse--who was making rounds throughout the unit) and the phlebotomist found the patient on the floor, I do not recall the (bed) alarm sounding...." Interview confirmed the bed alarm was not on prior to the fall. Interview confirmed all measures were not in place prior to the fall.

NC00134257