HospitalInspections.org

Based on documentation review and interviews, a hospital staff person failed to implement adequate fall interventions for 1 of 12 patients (Patient #1) who sustained a fall from bed. Findings include:

Patient #1's medical record was reviewed and revealed that s/he was admitted to the facility with weakness, severe malnutrition, and sores noted on his/her right lower extremity. S/he has a history of a traumatic brain injury. The patient is alert and oriented to person, place, and time, but due to severe developmental delay, is unable to communicate his/her needs. Due to weakness, the patient needed to be turned and repositioned, and was placed on a kinair bed to prevent further skin breakdown. His/her fall risk assessment determined that s/he was a high risk for falls, and safety precautions included: a door sign to alert staff of a fall risk patient, a fall risk wrist band, and all four siderails were to be up when in the kinair bed.

The Patient safety report, dated 7/1/2013 documents that at approximately 8:20 a.m., the patient was found on the floor next to the bed. Three side rails were up at the time of the incident, and the left lower side rail was found down. Nursing assistant/NA-I found the patient lying on the floor. NA-I notified Registered nurse/RN-F, who completed an assessment, and notified the house officer. The house officer ordered a computerized tomography scan/(CT) scan of the head and neck, and an xray to rule out rib fractures. No injuries were found on the CT scan or the xray. Following the incident, the patient was placed on a low bed with an air mattress, and a floor mat was placed next to the bed.
NA-I was interviewed on 10/25/2013 at 9:28 a.m. and stated that on the day of the incident, s/he walked into patient #1's room at the beginning of day shift, and saw the patient on the floor. The patient was lying on the floor, horizontal to the bed, near the bottom of the bed. S/he stated that all four side rails were up. S/he called a code for assistance, and RN-F, and other nursing staff came into the room to assist with the patient. S/he left the room when RN-F arrived. S/he verified training regarding the kinair beds, and was aware that all siderails need to be up when a patient is in the kinear bed.
RN-F was interviewed on 10/3/2013 at 10:45 a.m. and on 10/25/2013 at 2:47 p.m. and stated at approximately 8:00 a.m. on 7/1/2013, the patient was found by NA-I on the floor, and s/he called a code for staff assistance. When RN-F entered the room, s/he noted the lower left side rail of the bed was down. The patient was observed to be on the floor, next to the left lower side of the bed. RN-F completed an assessment, and called the house officer for an evaluation. The house officer ordered a CT and a xray to rule out injuries. No injuries were found. A post fall huddle was completed with staff involved in the incident, and interventions implemented to prevent further falls was discussed. A low bed and floor mat was implemented. RN-F stated that the night shift nurse verified that all four side rails were up at the end of the night shift.
A review of the Falls/Assessment of Fall Risk and Prevention Interventions policy, dated 2013, noted "four side rails are considered a restraint unless used for seizure precautions or for specialty beds and mattress overlays."