HospitalInspections.org

Based on document review, observation and interview, it was determined the Hospital failed to ensure nursing care plans were developed in accordance with the patient needs. This has the potential to affect all inpatients at a Hospital with a current census of 95 in-patients.

Findings include:

1. The policy titled "Fall Prevention Program" (revised 1/25/21) was reviewed on 11/22/22. The policy noted "2. All patients/residents are assessed for risk of falling... as part of the admission process, every shift, as needed... B.. Standard Safety Precautions will be implemented on all patients... h. Educate patient/resident/family on general fall safety; and i. In cases where patients are escorted to the bathroom or shower, encourage patients to call for assistance... 2. Patients Identified as "High Risk" for Falls... a. Note fall risk in the care plan b. Add the alert identifier to the patient's identification band. c. Add fall risk signage. d. Place patient in yellow gown to alert all departments and staff as a potential risk for falls...h. Consider utilization of a bed or chair alarm for patients who are unable to follow safety direction. i. Consider use of patient safety attendant. j. Consider the use of three (3) side rails... k. Consider use of low bed. 3. Patients Identified as "At Risk" for Injury...a. Add fall risk for injury signage. b. Place a floor mat along the exit side of the patient's bed."

2. The Electronic Medical Record "Fall Risk: Assess (Assessment)" screen shots where reviewed on 11/22/22. The Fall Assessment questions are as follows: Fall history/Anticoagulation Therapy (Blood Thinner); Heindrich II scale- confusion/disorientation/impulsiveness, depression, altered elimination, dizziness, gender, anti-seizure medications/benzodiazepine (anti-depressant drugs); get up and go test (rising from chair). The assessment noted a fall risk score greater than 5 was "High Risk" and a score less than 5 the patient is still considered a fall risk. A second fall risk assessment questions are as follows:, age grater than 85, bone disease or fractures and anticoagulant use. The assessment noted if 2 or more of the questions were answered "yes" completes the following: Do Not Leave Alone in BR (Bathroom) and Nonslip mat exit side of bed.

3. Pt # 8 DOA (Date of Admission): 11/21/22
Diagnosis: Chronic Obstructive Pulmonary Disease with Hypoxic Hypercapneic Respiratory Failure. The record was reviewed on 11/22/22 at approximately 2:00 PM. The record noted Pt #8 had impaired oxygenation which required Bipap (oxygenation device), anemic (decrease blood levels), on a blood thinner and a diuretic, treated for depression and activity was greatly limited due to shortness of breath. Four Fall Risk Scores between 11/20/22 and 11/22/22 varied from 0-5 without change in the patients system assessments.

4. Pt #9 DOA: 11/16/22
Diagnosis: Shortness of Breath. The record was reviewed on 11/22/22 at approximately 1:30 PM. The record noted Pt #9 had a cardiac monitor for abnormal heart rate, anemia (decreased blood levels), received Opioids, anticoagulated, pathologic compression fracture and was 85 years old. Twelve Fall Risk Scores between 11/16/22 and 11/22/22 varied between 0-3 (8 were documented as no risk "0") without change in the patients system assessments. Two assessments noted nonslip mat was placed on the exit side of the bed.

5. Pt #11 DOA: 10/20/22
Diagnoses: Diarrhea and Syncope (Fainting). The record was reviewed on 11/23/22 at approximately 10:00 AM. The Fall Risk Assessment dated 10/20/22 at 6:00 PM noted a fall risk of 5 and a prevention measure "Do Not Leave Alone in BR (Bathroom)". The Nurses Notes dated 10/20/22 at 11:55 PM noted "Bathroom call light went on, upon arrival to room patient found sitting on the floor in the bathroom with IV (Intravenous) out... Will call supervisor for telesitter." The Nurses Note dated 10/21/22 at 3:40 AM noted "Telesitter initiated at this time for patient's safety.", greater than 3 hours post fall.

6. Pt #15 DOA: 10/12/22
Diagnoses: Vomiting and Seizure Disorder. The record was reviewed on 11/22/22 at approximately 4:30 PM. Six Fall Risk Scores between 10/18/22 and 10/20/22 varied from 2-12 without change in the patients system assessment.

7. During a tour of 3 West and the Medical Intensive Care Unit (MICU) on 11/22/22 at approximately 11:45 AM with E#10 (Director of MICU and Surgical Intensive Care Unit (SICU), patients identified as on Fall Precautions were observed to lack the following:
a) Pt #8, lacked fall precaution signage;
b) Pt #12 DOA: 11/13/22 was observed to be up in a chair without a chair alarm;
c) Pt #13 DOA: 11/20/22 lacked a yellow gown, an alert identifier on the armband, lacked a bed alarm (deactivated);
d) Pt #14 DOA: 11/10/22 lacked an alert identifier on the armband.

8. During an interview on 11/22/22 at approximately 10:30 AM, E#9 (Director of Regulatory and Compliance) stated "There are multiple considerations when determining a fall risk score and prevention measures. The Henrichs assessment provides a fall risk score but also age, medications and overall condition play just as much of a role as the Henrichs."

9. During an interview on 11/22/22 at approximately 12:30 PM, E#11 (Educator and Leader of the Fall Committee) stated "We don't do audits (fall precaution compliance). We did audits March of 2021 for about three weeks. Initially we found bed alarms off and socks not on but we corrected the errors with staff in real time. By the end of the 3 weeks, compliance was good."

10. During an interview on 11/22/22 at approximately 3:30 PM, the Director of Surgery (E#8) and E#4 (Director of Quality) stated "3 West does not use floor mats." E#8 and E#4 where unable to answer how the electronic medical record calculated the fall risk score as of 11/23/22. E#8 reviewed the above records and verbally agreed Fall Precaution Scores were incorrectly assessed and appropriate intervention and precautionary measures were not implemented and should have been.