HospitalInspections.org

Based on interview and record review it was determined the hospital failed to ensure that nursing staff kept the nursing care plan current for 1 of 10 sampled patients who had experienced falls (Patient 5). Findings include:

Hospital records indicate that Patient 5 had been admitted to the facility on 1/30/12 with a complex medical condition including a history of bladder cancer, mitral valve replacement, multiple TIA's, Cardiomyopathy and "abdominal pain." The "Patient Health History and Admission Record" completed at that time indicated that the patient required "assistance" with bathing, dressing, ambulation and toileting, and was considered a "fall risk."

A "Patient Plan of Care," including a "Morse Fall Scale Score" assessment was also completed on 1/30/12. That assessment identified that Patient 5 was at "High Risk" for falls. A variety of interventions were planned to help reduce the risk of falls, including the use of a bed alarm and side rails, and to "educate pt. on use of call light." According to the 1/30/12 Plan of Care these interventions were to be "on-going."

The "Patient Plan of Care" for 1/31/12 also addressed a variety of "safety" interventions, including the use of side rails and [stand-by assistance] when [out of bed] with [front wheel walker] and [bed alarm as needed] (SBA OOB FWW, BA PRN)." The safety goal for the day was to "avoid falls with injury."

The "Patient Plan of Care" for 2/1/12 was also reviewed. That review revealed that a "Morse Fall Scale Score" assessment was again completed, and that Patient 5 continued to be at "High Risk" for falls. However, the safety/fall prevention interventions of 1/30 and 1/31/12 were not continued onto the new care plan.

Although Patient 5 was still assessed to be at high risk of falls, the 2/1/12 plan of care failed to identify any safety concerns or planned interventions to prevent falls. It was not clear if the safety interventions of 1/30 and 1/31/12 were still "on-going." The plan for 2/1/12 provided no direction or indication of how Patient 5 was to be assisted when out of bed, or toileted.

Documentation in hospital Progress Notes, reflect that at 6:40 am on 2/2/12 Patient 5 "fell on floor while standing at bedside using urinal." Physical Therapy Progress Notes dated 2/2/12 reflect the patient "fell last night, per patient standing for urinal, [zero FWW or assist.] Documentation of radiology tests dated 2/4/12 revealed that Patient 5 sustained a "fractured right hip." That fracture resulted in Patient 5 undergoing surgical repair and further hospitalization.

Documentation in hospital records dated 2/7/12 reflect that Employee 3 reported he/she had left Patient 5 standing at the bedside with a urinal. Employee 3 reported he/she had left Patient 5 unattended, "in order to provide the patient with requested privacy."

On 9/12/12 Patient 5's "Patient Plan of Care" for the days of 1/30, 1/31, 2/1 and 2/2/12 were reviewed in detail with the Unit Manager and Risk Manager. In interview at 9:40 am both the Risk Manager and Unit Manager acknowledged that Patient 5 had experienced a fall at approximately 6:40 am on 2/2/12. The Unit Manager acknowledged that Patient 5's care plan of 2/1/12 failed to identify or address safety concerns and fall prevention interventions, and that the nursing care plan for 2/1/12 had not been kept current, as required.

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