HospitalInspections.org

Based on observation, interview, and record and policy review, the facility failed to have comprehensive policies and systems in place to stop patient falls and falls with injuries (395). This deficient practice affected four current patients #2, #4, and #10 who had falls with injury and patient #5 who was at risk for falls and three discharged patients #1, #3, and #9 who had injuries after a fall. The sample size was 10 and the current facility census was 16 patients.

Based on observation, interview, and record and facility policy review, the facility failed to update the care for patients who fell in order to prevent further falls from occurring. This deficient practice affected four current Patients #2, #4, and #10 who had falls with injuries and Patient #5 who was identified as at risk for falls and Patients #1, #3, and #9 who had falls with injuries and have since been discharged. The sample size was 10 patients, and the census was 16 patients.

Findings include:

1.The medical record review for Patient #2 was completed on 07/19/17. The medical record review revealed the patient was admitted to the facility on 6/22/17 with diagnosis of dementia with associated behavior. The medical record review revealed upon admission she was assessed as a falls risk due to confusion and use of orthopedic devices.

The medical record review revealed a care plan for activities of daily living that was initiated on 06/29/17 that stated the patient was independent for ambulating. It stated the patient uses both a cane and a walker for ambulation. It did not reveal what interventions or precautions to put in place to address the falls risk.

The medical record review revealed an interdisciplinary treatment plan that was begun on 06/30/17. Review of that plan did not reveal how the falls risk would be addressed.

The medical record review revealed the patient fell unwitnessed in the bathroom on 07/03/17. The review revealed a note dated 07/03/17 at 9:00 PM that stated she was found on the floor with blood noted on the floor and on her face and that there was swelling to the face. The patient was transported to a local emergency room.

Further review of the medical record review revealed a note dated 07/04/17 at 1:45 AM that stated the patient had returned from the emergency department with no fractures found. The note stated, "Major tissue damage around left eye and left forehead. Major bruising is present."

The medical record review revealed the care plan described the patient as independent for ambulation unchanged, and the treatment plan updated on 07/04/17 to include a goal of the patient not falling during hospitalization with interventions to include reviewing medication administration, placing a yellow arm band on the patient to increase awareness of risk of fall to patient and staff, and performing safety checks every 15 minutes. The treatment plan did not address how to manage her ambulation.

Review of the facility's "Fall Risk and Data Collection Protocol" effective 11/2015 was completed on 07/19/17. The review revealed the interventions listed in the treatment plan were already in place as a matter of policy:

a. The review revealed the yellow arm band was to have been placed when the patient when the patient was first identified as a fall risk. The policy states, "A yellow arm band will be placed on all pts that are identified as a fall risk."

b. Review of the policy states patients are to be observed for side effects of medications.

In addition, review of the policy revealed the interdisciplinary treatment plan should have addressed the falls risk when it was created on 06/29/17. The policy states the team is to evaluate the patient's fall risk in conjunction with the care plan.

The medical record review revealed a nursing note dated 07/04/17 at 7:50 AM that stated the patient's bed alarm was on.

Review of the treatment plan and the care plans did not reveal when the use of a bed alarm was to have begun.

On 07/17/17 at 11:40 AM the patient was observed in the day room in a regular chair at a table with a rolling walker next to her. Bruising was observed on the left side of her face from the temple down to her neck.

On 07/18/17 at 4:22 PM in an interview, Staff D confirmed the care plan stated the patient was independent for ambulation, did not address risk for falls, and was not updated since its creation and after the patient had fallen, or when use of the bed alarm was initiated.

2. The medical record review for Patient #4 was completed on 07/18/17. The review revealed the patient was admitted to the facility on 07/07/17 with a diagnosis of dementia with associated behaviors, Alzheimer's disease, and diabetes.

The medical record review revealed a falls risk assessment dated 07/07/17 at 5:58 PM that stated the patient was at risk for falls because of a history of falls, confusion/disorientation, and an unstable gait and balance.

Confirming the fall risk assessment, the medical record review revealed a nursing note dated 07/07/17 at 10:57 PM that stated the patient was agitated and unsteady when walking down the hallway. The note continued, "Patient lost his balance landing on knees. Patient continues to be agitated hitting and kicking at staff. Patient able to get up on own. Denies discomfort at this time." The note finished by stating, "Staff to assist with ambulation."

The medical record review revealed a nursing note dated 07/08/17 at 1:00 AM that stated at 12:18 AM, "Staff heard a thud and entered the restroom to find the patient sitting on the floor leaning up against the wall in his shower. Staff assessed patient for injuries, noting a red abraded area on his posterior right shoulder and bump on the right side posterior scalp. Vital signs taken and neuro checks initiated."

The medical record review revealed on 07/08/17 a care plan was created that stated the patient's gait was unsteady with minimal assist for ambulating. The care plan does not describe the need for any assistive devices, nor does it address the risk of falls, nor does it echo the note of 07/07/17 at 10:57 AM that states staff are to assist with ambulation.

The medical record review revealed on 07/09/17 a fall prevention care plan was placed into the treatment plan. Like Patient #2, interventions listed are those found in the "Fall Risk and Data Collection Protocol" effective 11/2015. On 07/10/17, although the plan states the patient is "unsafe with walker, runs into others and objects, does not maneuver well," it is updated to state the patient ambulates with a rolling walker.

The medical record review did not reveal where either the treatment plan or the care was updated to reflect falls prevention in light of the fall in the bathroom on 07/08/17.

The medical record review revealed a nursing note dated 07/14/17 at 6:36 PM that stated the patient "was walking towards another patient's recliner to push in the foot rest. Patient was walking without his walker and attempted to push the foot rest of the recliner and fell backwards. Patient sustained a small skin tear on his middle knuckle of his left hand."

Review of the care plan did not reveal a change to reflect this fall, and review of the treatment plan revealed the patient is forgetful about using his walker and causes safety concerns when using it. Beyond monitoring, the treatment plan does not further address how to address the safety concern.

The medical record review revealed a nursing not dated 07/16/17 at 11:59 AM that stated the patient again fell in the hallway, but does not mention any injury.

On 07/18/17 at 4:22 PM in an interview, Staff D confirmed the care plan had not been updated.

3. The medical record review for Patient #9 was completed on 07/19/17. The medical record review revealed the patient was admitted to the facility on 05/25/17 with a diagnosis of dementia with associated behaviors. The medical record review revealed the 91 year old's behaviors at the extended care facility was worsening as evidenced by threats to break windows to get out.

The medical record review revealed a history and physical dated 05/25/17 that stated the patient was diagnosed with weakness and dementia and had had a total replacement of the left and right knee joints.

The medical record review revealed on 05/26/17 at 3:39 AM the patient was assessed as a fall risk due to his use of orthopedic devices, poor hearing, confusion, and unstable gait.

The medical record review did not reveal any care plan to address the fall risk. The medical record review did reveal a care plan for the patient's activities of daily living, initiated on 05/25/17 that stated although the patient needed minimal assist for ambulating, he uses a walker and wheelchair without describing under what circumstance each are to be used.

The medical record review revealed a nursing note dated 06/06/17 at 6:00 AM that stated the patient attempted to stand up "by self" in day room, and fell. The note continued that the patient was assisted back to his wheelchair.

The medical record review revealed a nursing note dated 06/06/17 at 6:47 AM that stated the patient complained of hip pain and the physician was notified.

The medical record review revealed a nursing note dated 06/06/17 at 11:35 AM that stated the patient, as a result of a portable x-ray taken earlier, needed to be further evaluated to rule out a hip fracture.

The medical record review revealed a nursing note dated 06/06/17 at 11:35 AM that stated the patient was sent to a local emergency department for further evaluation.

The medical record review revealed a care coordinator note dated 06/07/17 at 7:09 AM that stated an intensive care unit nurse was contacted who informed the writer that the patient had surgery for a fractured hip on 06/06/17 and was in the intensive care unit because he needed help breathing.

4. The medical record review for Patient #3 was completed on 07/18/17. The review revealed the patient was admitted to the facility on 06/22/17 for worsening of agitation and aggression toward staff. The medical record review revealed he was admitted for dementia associated with behaviors and anxiety disorder.

The medical record review revealed a care plan for activities of daily living that stated the patient was independent for ambulating as of 06/22/17 and did not address a risk for falls.

The medical record review revealed a treatment plan that was implemented on 06/23/17 to address a fall risk that reflected the "Fall Risk and Data Collection Protocol" effective 11/2015, namely, to review medication administration, place a yellow arm band on the patient to increase awareness of risk of fall to patient and staff, and perform safety checks every 15 minutes.

The medical record review revealed a nursing note dated 06/23/17 at 3:10 PM that stated the "patient was ambulating in the dayroom and attempted to sit in a recliner when he tripped over another patient's walker, he stumbled and fell to his knees."

The medical record review revealed the care plan for activities of daily living was left unchanged and the treatment plan had an entry on 06/26/17 that stated, "Patient had a fall on 06/23/17, tripped over a peers walker ...no further injury noted or verbal reports of pain".

The medical record review revealed a nursing note dated 07/07/17 at 11:02 PM that stated the author was walking past the patient's room when a puddle of urine was noticed outside the door. The note said upon entering the room, the patient was observed on the floor. Although the patient had been assessed as independent in ambulation, the note said the patient fell out of a wheelchair while attempting to go to the bathroom.

The medical record review revealed the care plan for activities of daily living was left unchanged and the treatment plan records, "Patient had an unwitnessed fall on 07/07/17. Patient transferred to [local emergency department] for evaluation ...". The documentation did not describe any modifications to the patient's care to prevent further falls.

On 07/18/17 at 4:22 PM in an interview, Staff D confirmed the care plan had not been updated.

5. The medical record review for Patient #10 was completed on 07/19/17. The medical record review revealed the patient was admitted to the facility on 06/16/17 with a diagnosis of dementia with associated behaviors. The medical record review revealed a history and physical dated 06/16/17 that stated she had a right humerus fracture prior to admission, and was diagnosed with dementia and anxiety disorder.

The medical record review revealed a fall risk assessment dated 06/16/17 that stated the patient was a fall risk because of the use of orthopedic devices, a history of falls, confusion, and poor eyesight.

The medical record review revealed a care plan to address activities of daily living. Initiated on 06/15/17, the care plan stated the patient used a cane and a wheelchair, but required minimal assist for ambulating.

The medical record review revealed a treatment plan for a fall risk dated 06/16/17 that like Patient #2, #3 and #4 echoed what was already in place by the "Fall Risk and Data Collection Protocol" effective 11/2015, namely, to review medication administration, place a yellow arm band on the patient to increase awareness of risk of fall to patient and staff, and perform safety checks every 15 minutes.

The medical record review revealed a nursing note dated 07/06/17 at 10:01 PM that stated the patient was found on the floor in the dayroom and a raised area to the right posterior scalp was found. The note stated the patient was assisted back to her wheelchair and taken to her room.

The medical record review revealed a nursing note dated 07/07/17 that stated the patient was found in her room between her wheelchair and bed.

The medical record review did reveal the treatment plan for the fall risk was updated on 07/06/17, stating, in full, "Patient unwitnessed fall on 07/06/17."

On 07/19/17 at 3:15 PM in an interview, Staff D confirmed that the care plan had not been updated with new interventions to address the new fall.

6. The medical record review for Patient #5 was completed on 07/18/17. The medical record review revealed the patient was admitted to the facility on 06/29/17 with a diagnosis of severe schizoaffective disorder.

The medical record review revealed the patient was assessed as fall risk on 06/29/17 at 9:36 PM due to use of orthopedic devices, a history of falls, and an unstable gait.

The medical record review revealed the patient had a care plan for activities of daily living initiated on 06/29/17 that stated the patient used a wheelchair and needed two to three people to assist with ambulation.

On 07/18/17 at 12:10 PM the patient was observed in a normal chair in his room. He was observed walking in his room and walking the halls without a wheelchair and without staff assistance.

On 07/18/17 at 4:22 PM in an interview, Staff D confirmed the care plan had not been updated.

On 07/19/17 at 10:30 AM Staff D confirmed the patient no longer needed to use a wheel chair.

On 07/17/17 at 2:30 PM in an interview, Staff B explained nurses decide on the spot what, if any, assistance a patient might need for ambulation. She explained a patient might need assistance today, but not tomorrow, and all nurses are free to make their own assessments and draw their own conclusions.

A review of the facility's falls management program was completed on 07/19/17. The review revealed the nurse is to complete a fall risk assessment in the computer software, is to review and revise the care plan as needed, and the care plan is to be monitored and the effectiveness of its interventions evaluated. In addition it includes a balance test, a timed up and go test, and a 30 second chair stand test. It does not explain how these tests relate to a final fall risk assessment.

The review of both the falls management program and the Fall Risk and Data Collection Protocol effective 11/2015 did not reveal how staff are to respond when they see a patient with a yellow arm band.

On 07/18/17 at 4:30 PM in an interview, Staff A could not explain what the facility's strategy was to prevent falls.


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7. The medical record review for Patient #1 was completed on 7/19/17. Patient #1 was admitted to the facility on 6/07/17 with diagnoses that included dementia with associated behaviors. The admission assessment of the patient completed by the RN on 6/07/17 at 5:55 PM determined the patient to be a fall risk. This was determined using the Fall Assessment that was part of the electronic health record.

The Fall Assessment is a 14 bullet point tool that evaluates characteristics that could contribute to a patient's risk for falling. Bullet point #6 asks if the patient has a history of falls. The nurse answered "yes" which assigned the patient ten points. Bullet point #7 asks if the patient is confused or disoriented. The nurse answered "yes" which assigned the patient an additional ten points. After the fourteenth bullet point the assessment reads, "To view score, click save, score will be listed in top left of the assessment. If total equals 10 or greater, place on fall precaution."

A paper Interdisciplinary Care Plan was found in the medical record with the title, "Fall Risk". Nursing interventions for the fall risk patient include assess medications for side effects, place yellow wrist band on patient and falling star magnet on door of room, and every 15 minute safety checks. The fall risk care plan was initiated on 6/08/17.

An "Occurrence Report Form" revealed on 6/09/17 at 3:30 PM "Patient was standing in the 300 hall and moved to get out the way of the housekeeping cart and stumbled over her feet and fell against the door of the housekeeping closet." The RN who witnessed the occurrence (Staff B) and wrote the report also wrote, "Neuro checks started, 1:1". Interview with Staff B on 7/17/17 at 2:40 PM confirmed "1:1" was written to indicate the patient would be in full sight of staff at all times. Review of the medical record did not confirm the patient was in full sight at all times and did not indicate when the 1:1 was started nor how long it should continue.

The electronic multidisciplinary team notes contain an entry by an RN dated 6/9/17 at 9:55 PM reading, "bed alarm on for safety". Interview with Staff A on 7/19/17 at 8:00 AM confirmed the entry at 9:55 PM was the first time the use of the bed alarm is mentioned. "I'm sure it was started that night as an additional nursing intervention after the patient's fall."

A review of facility policy, "Fall Risk Data Collection and Protocol" effective date 11/2015 was completed on 7/19/17. The policy reads, "All patients who are assessed as being at high risk for falls will be identified and individualized fall precautions will be developed for that patient." The procedure reads, "A fall risk assessment will be completed at the following times: 1) Upon admission/readmission to the facility, 2) With a significant change of status. If the assessment finds the resident at risk, implement appropriate interventions/precautions. Initiate, review and revise the fall care plan as appropriate, with new interventions, etc..."

The policy does not correlate with the electronic Fall Risk Assessment and does not list specific interventions nor a timeline to implement specific interventions or how to appropriately and systematically document and evaluate the effectiveness of the interventions.

Interview with Staff A on 7/19/17 at 8:00 AM confirmed these findings.