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UF HEALTH LEESBURG HOSPITAL
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on record review and interview the facility failed to provide care as needed to prevent falls for 1 of 6 patients (#5) reviewed.
Findings:
Review of the nurse's notes dated 1/5/11 for patient #5 revealed the patient was assessed as being at high risk falls. According to the patient's record, the interventions of call bell being accessible, 2 side rails, fall precautions, and bed in low position were identified.
The nurse's note dated 1/6/11 at 02:00 AM indicates that patient #5 was confused, getting in and out of bed, pulling at her intravenous lines, and picking. A vest restraint was placed. Further review of the nursing notes dated 1/6/2010 reveal that the patient had a sitter.
Review of staffing records for 1/6/2011 reveal that patient #5 had a sitter from 7:00 AM to 7:00 PM.
During an interview with patient #5's adult child on 3/2/2011 at 4:00 PM revealed that he/she had informed the facility of the patient's confusion and wandering and requested that a vest restraint be used.
Review of the nursing notes indicates that patient #5 had neither a vest restraint nor sitter after 7:00 PM on 1/6/2011.
Review of the nursing notes for patient #5 dated 1/6/2011 reveals that the patient had a fall in her room on 1/6/2011 at 8:25 PM and had a laceration and bruising of her face. Further documentation reveals that the patient was placed in a vest restraint after the fall.
Review of the nurses notes dated 2/2/2011 reveal that patient #5 did not have a vest restraint or sitter on 2/2/2011 at 7:32 PM when the patient was found on the floor with no apparent injury. Notes further indicate that after the patient was found on the floor a vest restraint was placed.
Correction Date: 4/1/2011