HospitalInspections.org

Based on medical record review, review of the facilities policy and procedures and staff interviews, the Acute Care Hospital (ACH) failed to ensure that 2 of 13 sampled patients (Patients 4 and 7) reviewed had documentation of a fall while a patient at the ACH. This failed practice has the potential to affect all patients of the ACH. The facility census on day of entrance was 563.

Findings are:

A. Review of Patient 4's medical record revealed the patient was admitted for 8 days (6/25/24 - 7/2/24) for a coronary artery bypass graft (CABG a surgical procedure that improves blood flow to they heart by rerouting blood around a blocked coronary artery) of one vessel. The patient had a fall on 6/27/24 between 3:00 AM - 3:45 AM. Review of the medical record revealed a lack of documentation of the post fall flowsheet in the electronic medical record (EMR).

B. Review of Patient 7's medical record revealed the patient was admitted on 8/15/24 for seizures. The patient had a fall on 8/16/24 at 2:00 PM. Review of the medical record revealed a lack of documentation of a fall risk assessment, seizure precautions, and equipment in use since 3:39 AM that morning. A fall risk assessment was completed after the fall at 2:14 PM. The patient scored a 25 which meant the patient was a high risk for falls. Documentation of equipment, alarms, and seizure precautions were not documented again until 8:10 PM that evening.

C. Review of facility policy titled Inpatient Fall Risk Assessment and Interventions (Dated 7/2024) revealed that a nurse will assess patients 15 years of age and older, using the Hester Davis Scale (a fall risk assessment 9 factor scale). This assessment will be performed at a minimum of once per 12-hour shift, and in the event of status clinical change. Documentation of equipment in use once per shift after fall risk assessment completed. In the event of a fall the nurse will complete the Post Fall flowsheet template within the electronic medical record.

D. Review of facility policy titled SOS Reporting (Dated 8/2023) Shout Out Safety (SOS) Reporting revealed completion of an SOS report does not replace documentation of the event in the medical record. Document in the medical record a statement of the event as it relates to the patient.

E. Interview with RN-A (8/22/24 at 10:30 AM) confirmed that Patient 4's medical record lacked evidence of the fall and the post fall huddle.

F. Interview with RN-B (8/22/24 at 2:53 PM) confirmed that Patient 7's medical record lacked evidence of the Hester Davis Scale, equipment, alarms, and seizure precautions in use since 3:39 AM on 8/16/24. RN-B also confirmed the medical record lacked documentation of equipment, alarms, and seizure precautions in use after patients fall on 8/16/24 at 2:00 PM until 8:10 PM.