HospitalInspections.org

Based on observation, interview, review of documentation in 4 of 4 medical records of Rehab Unit patients who had falls (Patients 1, 2, 3, and 4), and review of policies and procedures, it was determined that the hospital failed to fully develop and implement policies and procedures to ensure that the RN evaluated and supervised the provision of care to patients who were at risk for falls:
* Fall risk assessments were not consistently documented;
* Fall prevention interventions were not clearly assessed and consistently carried out, including the use of bed and chair alarms, and siderails;
* Documentation about the fall or incident event was not timely, clear and complete; and
* Post-fall interventions and documentation were not timely, clear and complete.

Findings include:

1. The policy and procedure titled "Fall Prevention & Management" with an effective date of 10/10/2013 was reviewed. The policy and procedure reflected the "Next Review" was due 10/10/2015. However, there was no evidence that a review had been conducted and completed. The purpose, policy and requirements portions of the document reflected the following: "To outline the fall prevention program to reduce the risk of patient harm resulting from falls...This policy establishes the PeaceHealth fall prevention and management program and aligns with community practices...Inpatient nursing units will use the following tools to assess the patient's fall risk and to plan fall prevention interventions and to document these actions...Fall Risk Assessment Tool...Fall Risk Prevention Precautions and Interventions...The Fall Management Procedure is implemented for a patient who has fallen..." The procedure portion of the document stipulated: "Falls assessment will be completed and documented upon admission, every shift and prn when condition changes...If a patient falls, immediately implement the following interventions...Assess the patient for injury before moving...Place patient in appropriate or desired position, take vital signs and perform a full body and neurological assessment...Notify the charge nurse and house supervisor...Notify the provide using SBAR. Initiate orders and diagnostic testing...Implement or re-evaluate the fall prevention interventions...Document the fall and post-fall interventions in the patient's medical record...Notify family of incident, treatment and patient's condition..."

The policy and procedure titled "Fall Prevention on Rehab" with an effective date of 06/12/2014 was reviewed. The document stipulated: "Nursing assesses the patient upon arrival and throughout the hospital stay, and follows the Falls Prevention policy:...Fall Prevention and Management...In addition...During the first 24 hours after admission...Bed alarm will be activated, unless the patient is assessed by all clinical disciplines and deemed not to be at risk for falls in the room....'Falling star' sign will be placed on patient's door...In the event of patient fall...Nursing will follow Policy...Fall Prevention and Management..."

The policy and procedure titled "Restraints and Seclusion" with an effective date of 10/23/2014 was reviewed. The document reflected that siderails were a "type of restraint." The only other reference to siderails in the document was in the definitions and was "A form of restraint composed of raising the side rails of a bed to prevent the patient from exiting the bed. This does not include methods that protect a patient from falling out of bed." There were no provisions or direction in the policy and procedure for patient assessment to distinguish between the use of siderails to prevent the patient from exiting the bed versus the use of siderails to protect a patient from falling out of bed.

In addition, although the "Restraints and Seclusion" policy and procedure referred to the use of siderails in the context of patient falls, there was no reference to siderails in the "Fall Prevention & Management" and "Fall Prevention on Rehab" policies and procedures.

2. a. The Rehab Unit falls list reflected that Patient 1 experienced a fall on 05/04/2015.

b. The medical record of Patient 1 was reviewed and reflected he/she was admitted to the Rehab Unit on 04/30/2015 at 0919. Pre-admission screening documentation by a physician on 04/29/2015 reflected that the 84 year old patient underwent a craniotomy on 04/14/2015 after findings of a subdural hematoma. The record reflected that while on the Rehab Unit on 05/04/2015 at 1855 the patient experienced a fall and a hip fracture and later that evening the patient was transferred to another PeaceHealth hospital with surgical capabilities.

On the day of admission to the Rehab Unit the physician's history and physical report dictated 04/30/2016 at 0943 reflected one of the patient's chief complaints was "Impaired cognition" and that "Neurologically, [he/she] scored 18/36 on the Montreal Cognitive Assessment..."

A Rehab Unit team report dated 05/01/2015 and not timed reflected that the patient had a "History of several falls...High fall risk...requiring [minimum] assist for bed mobility and [moderate] assist for partial stand pivot transfers to/from bed and toilet..."

During the patient's stay on the Rehab Unit fall risk assessments were not documented on two of 18 shifts. The 16 shift assessments that were documented identified the patient as at "high" risk for falls. There was no risk assessment documented on the day shift on 05/04/2015.

During the patient's stay on the Rehab Unit the use of bed and chair alarms as falls prevention interventions were not documented as in place on 11 of 18 shifts. Those shifts included: 05/03/2015 night shift; 05/03/2015 day shift; 05/04/2015 night shift; and 05/04/2015 day shift. There was no evidence of an assessment by the RN, and including all other clinical disciplines, to reflect that the use of alarms was not indicated.

Although the record contained references to the patient's altered cognitive status throughout, there was no documentation to reflect an assessment for the safe use and number of siderails as a falls prevention intervention for Patient 1. However, during the patient's stay on the Rehab Unit the use of siderails when the patient was in bed was documented on eight of 18 shifts and in all cases reflected 3 siderails were raised. Those shifts included: 04/29/2015 night shift; 04/30/2015 night shift; 05/03/2015 evening shift, and 05/04/2015 evening shift after the patient's fall.

On 05/04/2015 at 1610 an RN recorded on the falls assessment and interventions flow record that the patient was at "high" risk for falls and that "Bed/chair alarm in place [yes]; Bed/chair alarm checked - light on [yes]..." There was no documentation of the status of bed siderails.

In a narrative note also dated and timed on 05/04/2015 at 1610 the RN recorded: "Pt in bed, no c/o pain, having visual and tactile hallucinations...Pt's [spouse] put on call light to have assistance for pt to use the bathroom. Pt voided...Pt stayed up in w/c for dinner. At 1855, pt called out 'Help!' from [his/her] room. Pt was on [his/her] right side on the floor at the foot of the bed. Pt had tried to transfer to w/c, brakes were not on. Pt. said [he/she] was 'trying to go home'. Asked pt about pain, pt said [his/her right] knee was painful. Pt cried out when [right] knee was passively moved. Pt was 4 person assist up onto the bed, pt cried out in pain. Pt relaxed in bed, but cried out when distal portion of [right] knee was palpated. MD notified, received orders for xray, alarms, sitter...pt called [spouse], RN spoke to [spouse] and notified [him/her] of the fall. Ice applied to [right] knee. Pt said [he/she] did not hit [his/her] head, examined pt's head and found no bumps or abrasion, pt had no c/o head pain. Tylenol given at 2028. Xray done, MD contacted by radiology with results. Pt transferred to ortho at [another hospital]." There was no documentation of the status of bed siderails.

Inconsistent with the post-fall policy and procedure, the documentation reflected that the patient was not assessed for injury until after [he/she] was moved, vital signs were not taken, and a full body and neurological assessment was not conducted. There was no documentation to reflect that the house supervisor was notified.

In addition, although the fall was recorded to have occurred at 1855, the X-rays were not ordered until 1920, 25 minutes after the fall. The Imaging Reports record did not reflect when the X-rays were taken, however, documentation by a radiologist reflected that he/she dictated and signed the Xray report that reflected the patient sustained a fractured right femur at 2123, two hours and 28 minutes after the fall.

The documentation of the fall and the post-fall events in the medical record of Patient 1 does not clearly reflect the course of events on 05/04/2015, the day and evening of the patient's fall. A note in the record dated 05/04/2015 at 0730 reflected the patient had been discharged to another hospital. The note dated 05/04/2015 at 1610 described the patient's fall and indicated it had occurred at 1855, after the time the note was written. A Daily Nursing Care note was documented on 05/04/2015 at 2245, after the fall and diagnosis of a fracture, and reflected that the patient was "Up in Chair [yes]; Side Rails Up 3; Bed alarm/chair alarm [yes]; Bathroom privileges [yes]; Dangle [yes]; Assistive device used Walker; Assistance needed 1 person; Gait belt used [yes]..."

An Intercampus Transfer Physician Orders reflected that on 05/04/2015 at 2230 the physician ordered the patient transferred to the other PeaceHealth hospital in the adjacent city. Documentation in the patient's record reflected that on 05/04/2015 at 2350 the patient arrived to that hospital where he/she was admitted.

c. During interviews with the Regulatory and Accreditation Consultant and the DNS on 11/04/2015 between 1040 and 1155 it was reported that since March 1, 2015 there had been one hospital patient, Patient 1, who had sustained a fractured hip as a result of a fall. It was explained that the hospital uses beds that have four siderails attached, one on each side of the upper half of the bed and one on each side of the lower half of the bed. The interviews revealed that as a result of the hospital's investigation it was determined that causes of the fall included a lack of staff education and awareness related to siderail use. In addition, during the hospital's investigation Rehab Unit staff reported that all four siderails were raised at the time of the patient's fall secondary to family request to use all four siderails. The Regulatory and Accreditation Consultant acknowledged that in addition to changes in the patient's cognition, the use of all four siderails contributed to the incident as it impacted the patient's attempt to safely exit the bed by him/herself.

3. a. The Rehab Unit falls list reflected that Patient 2 experienced a fall on 09/26/2015.

b. The medical record of Patient 2 was reviewed and reflected he/she was admitted to the Rehab Unit on 09/18/2015 at 1411. During the patient's stay fall risk assessments were not documented on three shifts. Those shifts were: 09/22/2015 night shift; 09/28/2015 night shift; and 09/29/2015 day shift.

A nurse's note recorded on 09/27/2015 at 0900 reflected that the patient had fallen in the shower on the evening shift the day before, on 09/26/2015. Although there was a note that reflected the patient had showered on 09/26/2015 at 2140, there was no documentation of an incident or fall in the shower.

The post-fall documentation reflected that vital signs after the patient's shower, during which the incident was reported to have occurred, were not taken until 09/27/2015 at 0154, the neurological exam was not documented until 09/27/2015 at 0155, and only the musculoskeletal portion of the full body assessment was documented and not until 09/27/2015 at 0918.

4. a. The Rehab Unit falls list reflected that Patient 3 experienced two falls, on 10/04/2015 and 10/08/2015.

b. The medical record of Patient 3 was reviewed and reflected he/she was admitted to the Rehab Unit on 09/25/2015 at 1109. During the patient's stay fall risk assessments were not documented on four shifts. Those shifts included: 09/26/2015 day shift; 09/30/2015 evening shift; and 10/05/2015 day shift.

There was no documentation in the record to reflect an assessment for the use and number of siderails as a falls prevention intervention for Patient 3. However, during the patient's stay on the Rehab Unit the use and number of siderails when the patient was in bed was inconsistently documented on 19 shifts. On 12 shifts four siderails were documented as used and included: 09/28/2015 evenings; 10/02/2015 nights; and 10/03/2015 nights. On seven shifts three siderails were documented as used and included: 10/02/2015 evenings and 10/07/2015 evenings. There was no documentation of siderails used on 09/20/2015; 10/05/2015; and 10/06/2015.

An RN note recorded on 10/04/2015 at 2325 reflected that the patient fall had occurred at 2100. The post-fall documentation reflected that a full body and neurological assessment was not documented until 10/05/2015 at 0001, and the first vital signs taken after the fall were not recorded until the following day on 10/05/2015 at 0836.

Documentation on 10/08/2015 reflected that the patient's bed alarm sounded and staff responded to prevent a second fall for the patient.

5. a. The Rehab Unit falls list reflected that Patient 4 experienced a fall on 10/01/2015.

b. The medical record of Patient 4 was reviewed and reflected he/she was admitted to the Rehab Unit on 09/30/2015 at 0909. During the patient's stay fall risk assessments were not documented on ten shifts. Those shifts included: 09/30/2015 evening shift; 10/01/2015 evening shift; 10/09/2015 evening shift; and 10/12/2015 evening shift.

A note recorded on 10/01/2015 at 1232 reflected the patient's fall. The post-fall documentation reflected that the next neurological assessment was not documented until 1614, the next vital signs were not taken until 1630, and there was no full body assessment documented. There was no evidence that fall prevention interventions were re-evaluated. There was no documentation to reflect that the physician, the house supervisor, and the family was notified.

6. On 11/04/2015 at 1630 during tour of the Rehab Unit, a patient was observed in bed in room 472. Mobility devices were also observed in the room. During interview at the time of the tour the Rehab Unit Nurse Manager confirmed that Patient 5 had been admitted to the unit that morning, 11/04/2016 at 0845. He/she stated that a falls assessment had been done at that time and identified the patient was at risk for falls. However, at the time of the tour 7 hours and 45 minutes after the falls assessment, the "shooting star" sign, as a visual cue to staff that the patient was at risk for falls, was not observed posted at the entrance to the room.

7. During interview with the Regulatory and Accreditation Consultant and the DNS on 11/04/2015 between 1040 and 1155 it was confirmed that the "Fall Prevention & Management" policy and procedure was "out of date" and that the Falls Prevention Committee was working on a draft revision.

During the interview the use of siderails as a falls prevention intervention was discussed. It was confirmed that although there is documentation of siderail use in the daily care records in patient medical records, the use and number of siderails to be raised for each patient is not included in the nursing care plan, but is discussed with nursing staff in shift to shift nursing report.