HospitalInspections.org

Based on document review, observation, and staff interview, the nurse executive failed to ensure the high risk fall protocol was followed for 3 of 7 patients (patients #1, 6, and 7).

Findings include:

1. Review of patient #1 medical record indicated the following:
(A) He/she was admitted to the med/surg unit at 9:10 a.m. on 5/28/12.
(B) The patient was documented as a high risk for falls on document titled "FALL RISK FACTOR" and had a history of falls previous to hospital stay.
(C) The record indicated the patient was alert and oriented x 3 until after receiving a new medication in the evening of 5/29/13. He/she had refused the bed alarm be turned on prior to side effects of the new medication. He/she received Ativan 1 mg at 2300 on 5/29/12. The narrative notes indicated that at 0135 the spouse alerted staff that the patient was hallucinating. Upon entering the room, the staff documented the patient seemed to be very paranoid and was not aware of his/her surroundings. Notes at 0200 indicated the patient was still very paranoid and that his/her spouse was at the bedside. The spouse left facility at 0330. The patients bed alarm was not turned on after the spouse left.
(D) Narrative notes dated 0355 at 5/30/12 indicated the pulse ox was alarming. The patient was found on the floor "near the foot of the bed." The document indicated he/she was still disoriented.

2. Review of patient #6 medical record indicated the following:
(A) He/she was admitted 4/14/13 with episode of syncope (loss of consciousness).
(B) Per document titled "HIGH RISK ASSESSMENT", he/she was documented as a high risk for falls with a score of 4 (3 or more = high risk) and a history of falls prior to hospitalization.
(C) The care plan did not address a reason why the bed exit alarm would be turned off.
(D) He/she was cared for by LPN #1.

3. Review of patient #7 medical record indicated the following:
(A) He/she was admitted 4/10/13 with altered mental status.
(B) Per document titled "HIGH RISK ASSESSMENT", he/she was documented as a high risk for falls with a score of 7 (3 or more = high risk).
(C) The care plan did not address a reason why the bed exit alarm would be turned off.
(D) He/she was cared for by RN #1.

4. During observation of the med/surg unit beginning at 1:50 p.m. on 4/16/13 the following was observed:
(A) The bed alarms were off on the beds of patient #6 and #7. The patients were in the bed.

5. Staff member #4 indicated the following in interview beginning at 2:15 p.m. on 4/16/13:
(A) He/she verified that the bed alarmws were off and the reason for the bed alarms being off was not addressed on the care plans of patients #6 and 7.

6. LPN #1 indicated in interview at 2:30 p.m. on 4/16/13 that he/she did not know why the bed alarm for patient #6 was not turned on per facility policy.

7. RN #3 indicated in interview at 2:25 p.m. on 4/16/13 that he/she did not know why the bed alarm for patient #7 was not turned on per facility policy.

8. Facility policy titled "High Risk Fall Protocol, NS2.08" revised on 1/2012 (applicable policy for patient 1) states under "HIGH RISK INTERVENTIONS" on page 3: Patients classified as having a high risk for falls will be provided with all low risk interventions and the required interventions listed below........8. Assess need for Exit Alarms. As a guideline, it is recommended that patients with a history of previous falls or who scored higher than 5 will be placed on a Bed Exit Alarm........"

9. Facility policy titled "High Risk Fall Protocol, NS2.08" revised on 4/2013 (applicable policy for patients 6 and 7) states under "HIGH RISK INTERVENTIONS" on page 3: Patients classified as having a high risk for falls will be provided with all low risk interventions and the required interventions listed below........8. Assess need for Exit Alarms. As a guideline, it is recommended that patients with a history of previous falls or who scored higher than 3 be placed on a Bed Exit Alarm. If an alarm is not applied, a note regarding the reasoning should be made on the care plan."