HospitalInspections.org

13692

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Based on interview, record review, and review of the hospital's quality improvement program and performance data, the Critical Access Hospital failed to 1) thoroughly investigate and document all factors which may have contributed to patient falls for 3 of 9 patients reviewed (Patients #4, #5, and #8); and 2) ensure data regarding patient falls were aggregated and analyzed for common factors through the hospital's quality program.

Failure to systematically collect and analyze data regarding patient injuries limits the hospital's ability to develop action plans to prevent future injuries.

Findings included:

Item #1 - Investigation of Patient Falls

1. On 04/02/19 and 04/03/19, the investigators reviewed the records of nine patients who had experienced falls with minor to serious injuries during their hospital stay with the assistance of the hospital's nurse manager (Staff #2). This review showed that staff failed to thoroughly investigate and document all factors which may have contributed to the falls for 3 of 9 patients reviewed (Patients #4, #5, and #8). Documentation of these incidents did not identify whether or not the use, lack of use, or function of equipment used to provide care for the patients contributed to the falls:

a. Patient #4 fell on 07/04/18 and resulted in a serious injury. Review of records showed no evidence that staff investigated whether or not a gait belt was used at the time of the fall as directed by the most recent nursing assessment dated 05/10/18;

b. Patient #5 fell on 11/05/18 when a wheelchair slipped out from under her as she sat down. Review of records showed no evidence that staff thoroughly investigated whether or not the brakes on the wheelchair had been on when the fall occurred.

c. Patient #8 fell on 01/16/19 when he tipped forward in a recliner. Documentation showed a chair alarm was in place at the time of the fall, but had not sounded to alert staff. Review of records showed no evidence that staff thoroughly investigated why the alarm did not sound, or how to prevent alarm failure in the future.

2. On 04/03/19 at 10:30 AM during an interview with the investigators, the nurse manager confirmed that the records lacked evidence that the fall investigations included all factors which may have contributed to the falls.

Item #2 - Analysis of Patient Fall Data and Development of Action Plans for Improvement

1. Review of the hospital's policy titled "Quality Assurance and Performance Improvement (QAPI) Plan", policy #605021 dated 03/19, showed that the hospital's quality program would include collection and analysis of data regarding patient falls. The plan stated that the hospital's QAPI committee would develop action plans for improvement as indicated by the results of this analysis.

2. On 04/03/19 from 8:55 AM to 9:50 AM, the investigators interviewed the hospital's quality program manager (Staff #1) and reviewed the hospital's quality program and performance data. This included review and discussion of data regarding patient falls. The interview and data review showed there was no evidence of data analysis and development of action plans when the number of patient falls increased during the months of November 2018 and January 2019. Incidents of patient falls that occurred in 2018 and 2019 were not aggregated and analyzed for patterns, trends, and common factors between events to determine if care delivery system changes were required to prevent future patient falls.