HospitalInspections.org

Based on policy and procedure review, medical record review and staff interview the nursing staff failed to implement High risk fall precautions to prevent the falls on 2 of 5 patients (#13, #17)

Findings include:

Review of policy and procedure titled "...Patient Falls, Fall documentation..." revised on 01/21/2015 revealed "...POLICY:...The purpose of this policy is to define a comprehensive fall prevention and management program to reduce falls ad prevent injury from falls....DEFINITIONS:...Fall: An unplanned, unintentional change in position that causes an individual to land at a lower level, on an object, on the floor, or on the ground. A fall may be witnessed, un-witnessed, or assisted...PROCEDURE:...General...1 ....Basic safety interventions include, but are not limited to, the Fall Bundle, environmental assessment, and risk assessment through the Morse Fall Scale ....2. The Fall Bundle, applicable to all patients, includes the following interventions:...Environmental: orientation to environment, room clutter free, cords managed, appropriate footwear /nonslip socks for ambulation, offer the use of night light in room, Call, Don't Fall sign, and the "Call, Don't Fall" Contract....Bed: bed in low position, brakes on, top bed rails up at all times...Possessions: call light and patient belongings are within reach of patient...Educate patient and family to request assistance for all transfer and ambulation...Hourly Rounding by staff ...Anticipated Physiological Fall...1. A Morse Falls Scale is used throughout...to predict patients at risk for falls. All inpatients are assessed by the licensed nurse for fall risk using the Morse Fall Scale upon admission, with reassessments routinely performed at least each shift....3....Risk levels are as follows ....Low Risk 0-35...High Risk 36 and greater...4. The Fall Bundle will be implemented for all patients....5. The following interventions are implemented by the licensed nurse, in addition to the Fall Bundle and high risk interventions, for patients assessed as high risk for falls...Bed and chair alarms on ...Place the patient closed to the nurse's station for observation...discuss medication changes with pharmacist...Consider consult for PT /OT Evaluation...Provide continuous supervision when the patient is in the bath room or on the bedside commode... Monitor every 2 hours and offer toileting, positioning, personal care or need of pain medications if awake...place yellow bracelet on patient's arm ... Placement of yellow "Falling Star" on outside doorframe of patient's room...."

1. Closed medical record review revealed a 36 year old Pt (patient) #13 was admitted to the inpatient third floor from the ED (Emergency Department) on 05/20/2016 at 2120 with the diagnosis of chronic pain. The H&P (History and Physical) documented the "...CHIEF COMPLAINT: Headache, Right leg numbness. Weakness and falls....with history of chronic low back pain...". Record review revealed a fall risk assessment was performed by Staff #4 a RN (Registered Nurse) on 05/20/2016 at 2252 with a fall risk: "HIGH" and a Morse fall scale of 45. Further record review revealed the next fall documentation is on 05/21//2016 at 0638 during environmental checks (safety checks) by the NA (Nursing Aide) ) revealed the following fall precautions were implemented: "...Bed in Low position...Bed Locked...Call Bell in Reach...Siderails up x 2...Personal articles in reach...Room clutter free...Trash emptied...". There was not any documentation of the following high fall risk interventions being implemented: yellow arm bracelet, yellow fall star outside room on the doorframe or the bed alarm was set for Pt #13. Record review revealed the assigned RN documented on 05/21/2016 at 1000 that Pt #13's Morse fall scale had increased to 55 and at 1435 environmental checks noted by the NA that the bed and chair alarms were not on. Further record review revealed that the RN documented at 1730 that the Morse fall scale increased to 95. On 05/21/2016 at 1735 the RN documented that Pt #13 "...PATIENT PUSHED CALL BUTTON TO ALERT STATION THAT SHE HAD FALLEN. I WENT TO PATIENTS ROOM AND SHE WAS SITTING IN THE FLOOR....". The following high risk fall precautions were implemented at 1810: "...FALL BRACELET APPLIED TO PATIENT. FALL STAR ON DOOR. BED IN LOWEST POSITION, CALL BUTTON WITHIN REACH AND BED ALARM ON...." for Pt #13 by the RN. Record review revealed high risk fall precautions interventions were not followed per policy for Pt #13.

Interview on 08/18/2016 at 1605 with Staff #7, a RN, revealed there was not a high risk falls star outside Pt #13's door prior to the fall. Interview revealed that if the RN would have known that Pt #13 was on high risk fall precautions, she would have made sure the yellow bracelet was on, bed in lowest position, bed alarm on and siderails up x 2. Further interview revealed that she was not sure that the policy had been followed for Pt #13 with a Morse scale of 45. Interview revealed high risk fall precautions interventions were not followed per policy for Pt #13.

2. Closed medical record review revealed an 84 year old Pt (patient) #17 was admitted to the inpatient second floor at 2100 to room 228 with a complaint of neck pain and a diagnosis of "GAS EXCHANGE IMPAIRMENT" (condition of the lungs) on 07/14/2016 at 2100 from the ED (Emergency Department). Pt #17 was legally blind, can see shapes, and hard of hearing. The patient had a history of hypertension (high blood pressure), congestive heart failure (condition of the heart), and migraine (extreme headache). Record review revealed patient #17 arrived to the unit on a stretcher with an allergy and fall bracelet intact. Further record review revealed that Pt #17 was placed on fall precautions on 07/14/2016 through 07/18/2016 with a Morse Score of 45. The next documentation of fall assessment was on 07/18/2016 2200 with a Morse Score of 75. Record review revealed between 07/14/2016 and 07/19/2016 high risk fall interventions (the call bell was in reach and the bed alarm was on) were only documented on 07/17/2016 at 0615. Further record review revealed on 07/18/2016 at 2045 a RN (Registered Nurse) documented that Pt #17 was trying to "...CLIMB OUT OF BED AND SHE STARTED PULLING ON HER IV..." Review revealed the nursing supervisor was notified that Pt #17 was being moved from room 228 to room 200 (closer to the nursing desk) for closer observation. Pt #17 was transferred to room 200 by a RN, night House Supervisor and a RN in training via the patient's bed. Record review revealed at 0305 Pt #17 was found "...ON FLOOR...". All the bed side rails were up, the light was on over the sink and the door was wide open but the bed "...ALARM WAS NOT WORKING...". Record review revealed the bed alarm was not applied according to the high risk fall precautions policy.

Interview on 08/18/2016 at 0830 with Staff #1, a RN, revealed she remembered Pt #17 was in room 228 calm and asleep when she began her shift on 07/19/2016. Later during the night she heard the bed alarm from room number 228. She proceeded to check on Pt #17 and found her sitting on the side of the bed with the side rails up and complaining of wanting the IV out. Staff #1 then notified Staff #2, the night House Supervisor, that she was going to move Pt #17 to room #200 near the nursing desk for closer observation. Interview review revealed that the House Supervisor and the RN in training moved Pt #17 to room number 200 in the patient's bed. Interview revealed after hearing a noise Pt #17 was found lying on the floor. Interview revealed after the room transfer the bed alarm did not work and the bed alarm remained off after Pt #17's room change. Staff #1 stated that it was discovered that the bed cord was plugged into the wall outlet but the end of the cord to the bed was not completely plugged in. Interview revealed high risk fall precautions interventions were not followed per policy for Pt #17.

Interview on 08/18/2016 at 0915 with Staff #2, the night House Supervisor, revealed she was asked to assist Staff #1 with moving Pt #17 from room 228 to room 200. Interview revealed after the Pt #17 was transferred, Staff #1 attempted to set the bed alarm and it would not work. She instructed Staff #3 to unplug the bed for fifteen to twenty seconds hoping that the bed will reset. The bed did not reset itself. Interview revealed Staff #2 was interrupted and became busy and forgot to return to reset the bed. After hearing the fall and finding Pt #17 lying on the floor, the decision was made to remove the bed out of the room and exchange with another bed. Interview revealed Staff #2 and another CNA (Certified Nurse Assistant) moved the bed and noticed the connection to the bed was loose. The cord was re-connected to the bed and the alarm worked. Interview revealed Staff #2 saying "I did not completely follow policy that night...If I could I would do things differently..." Interview revealed high risk fall precaution intervention (bed alarm on) was not followed for Pt #17.

NC00119603