The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
| CYPRESS CREEK HOSPITAL | 17750 CALI DRIVE HOUSTON, TX 77090 | July 22, 2015 |
| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure 7 of 11 patients (#'s 5, 3, 13, 9, 10, 11, and 12) reviewed received care in a safe setting as evidenced by: -Patient #5 was not assessed correctly for Risk of Falls -One patient's (#10) MTP (Master Treatment Plan) was not updated after his fall. -Patient #13 and #12's Daily Fall Risk Assessment was not completed twice a day after falls as per the facility's Policy and Procedure. -Patients' 3, 13, 9, 10, 11 and 12 assessments as Moderate Risk, Level II or High Risk, Level III for falls were not consistently noted in the daily Nurses' Notes or on the Patient's Safety Observation Round Sheets. The areas were left blank or noted at a lower level. Patients 13, 9, 10, 11 and 12 fell during their stay at the facility. Findings Include: Record review of the facility's Policy and Procedure for Fall Prevention & Reduction dated 4/27/93 and revised on 1/11/15 revealed the following: "Purpose 1. To protect patients and promote patient safety. 2. To effectively identify and interne (sic) with patients that are at risk for falling. 3. To establish a mechanism to effectively identify and intervene with adult patients that have a potential risk for falls by establishing a prescience fall prevention and reduction program... Policy... 8. A risk Assessment will be completed by a Registered Nurse (RN) on all patients at the time of admission to the unit. The RN will be responsible for establishing and updating the individual Master Treatment Plan (MTP) related to prevention and safety... 9. All patients will be assessed for risk of falling upon admission and on the daily RN Shift Assessment. Patients identified to be at risk for a fall will be placed on fall precautions accordingly (Moderate Risk Level II or High Risk - Level III) to promote prevention and reduction. Fall Risk Scores are as follows: 7-9 = Moderate Risk Level II and 11 or greater = High risk - Level III Fall 10. Patients who sustain a fall well be reassessed at the time of fall and immediately placed on the High Risk - Level III category and an MTP for Falls or an update. All subsequent falls will require a reassessment and an MTP update. Interventions will be implemented as indicated. Procedure... a. Fall precautions will be documented on the Patient Safety Observation Round Sheet... c. If the patient's score is 11 or greater, Fall Precautions will be implemented in accordance with the Safety Observation Precaution Policy. d. If a Fall risk Level III is identified a patient will be placed on Fall Precautions immediately. i. The patient's room assignment will be close to nurses' station when conditions permit ii. A Bell will be provided and patient will be instructed to use the bell to call for staff assistance for ambulation, toileting, and hydration as needed.... 12. Shift Assessment - a. Fall risk will be assessed twice daily and documented on the Daily Nursing Assessment Sheet... c. If a patient's condition changes or at the nurse's discretion Fall Precautions may be initiated by (sic) will require a physician order to discontinue once implemented.... 13. d. Patient will be placed on High Risk - Level III Fall Precautions, a Daily Fall Risk Assessment will be initiated and completed daily until patient scores 10 or below. Patient safety measures will be modified and immediately implemented in accordance with the Fall Risk Assessment and documented in the MTP." Patient #5 Record review of Patient #5's active medical record revealed he was a [AGE] year old male admitted on [DATE] with suicidal ideation with audio/visual hallucinations and depression. Record review of Patient #5's medical record revealed a bright green sheet labeled "Hand-Off Communication dated 7/14/15 at 5:25 p.m. that noted at Fall Risk that the patient had a history of falls with one dated 7/10/15. There was a Part I Medical Screening Evaluation dated 7/14/15 under History of Fall? that circled "Yes" and noted the patient fell on [DATE] at the hospital. Record review of Patient #5's Fall Risk Assessment and Safety Measures sheet dated 7/14/15 revealed he scored a 3, all in Medications. The fall risk levels were as follows: Score 7-10 = Moderate Risk - Fall Risk level II Score 11+ = High risk = Fall Risk level III The patient was not considered a fall risk. There was a section on the form for MOBILITY with one criteria for History of Falls within 4 weeks Prior to Admission. That would have scored 7 points alone and made the patient's total score 10. The patient would have been at Moderate Risk for falls at a level II. Record review of the facility Daily Census Report for Unit 4 General Adult unit dated 7/21/15 showed Patient #5's Fall Risk was a level 1 and he was independent for ADLs (Activities of Daily Living). Review of Patient 5's Patient's Safety Observation Round Sheets revealed the Patient was noted to be independent and at Risk level 1. Interview on 7/21/15 at 1:00 p.m. with MHT (Mental Health Technician) #55, he said the Fall Risk was at a I, II or III. A one meant the patient had a steady gait, a 2 meant an unsteady gait, and a 3 was the patient used a wheelchair or a walker. He said if the patient was at risk II or III he would have to stand closer to the patient if they left the unit. He said the risk level was on his monitoring sheet and on the marker board at the nurses' station. He said he would also find out about patients during the morning report. Interview on 7/21/15 at 1:10 p.m. with CNO (Chief Nursing Officer) #51, she said Fall Risk I needed to be removed from the form. She said the Risk Assessment used to be 1,2,3, but now it is Moderate Risk/level II or High Risk/level III. She was asked what was done differently for patients on moderate or high risk. She said the MHTs would monitor the patient more closely, the staff would give the patient a bell to use at the bedside for assistance, and the facility would try to have the patient moved closer to the Nurses' Station. She said if the patient was cognitively impaired they would put the patient on one to one monitoring. She said the patient might be put on a mattress in the day room to sleep at night if they could not be in a room close to the Nurses' Station. She said the nurses used a Daily Fall assessment sheet for all patients at high risk for falls. She said Patient #5 should be Moderate Risk - Level II precautions. She said the nurse missed the information about his prior fall. The CNO said the Part 1 Medical Screening sheet was filled out by the triage nurse in the triage area prior to admission to the unit. Patient #3 Record review of Patient #3's active medical record revealed she was a [AGE] year old female admitted on [DATE] with suicidal ideation. Record review of Patient #3's Fall Risk Assessment and Safety Measures sheet dated 7/20/15 revealed an assessment score of 9 which was Moderate Risk, level II. Record review of the Unit 4 Daily Census Report revealed Patient #3 was fall risk II. Interview on 7/21/15 at 1:00 p.m. with MHT #55, he said Patient #3 was at fall risk I. He showed the monitoring sheet for Patient #3 and risk I was circled. Patient #13 Record review of Patient #13's closed medical record revealed he was a [AGE] year old male admitted on [DATE] with an exacerbation of paranoid Schizophrenia. Record review of Patient #13's Fall Risk Assessment and Safety Measures sheet dated 7/27/15 revealed a risk score of 6 which was a low risk for falls. Record review of Patient #13's Nurses' Notes dated 5/29/15 revealed he tripped on the leg of the couch and fell . Review of the patient's Nurses' Notes dated 6/15/15 revealed he fell in the shower. Further review of the Nurses' Notes from 5/29/15 to discharge on 7/11/15 revealed no documentation of the fall precautions for the following dates: May - 31st June - 1st, 2nd, 6th, 8th, 9th, 10th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, 21st, 22nd, 23rd, 24th On the following dates the fall precautions were either marked as a I or II: June - 25th, 27th, 30th July - 1st, 2nd, 3rd, 5th, 7th, 9th Record review of Patient #13's Physician's Orders from 5/29/15 to 7/11/15 revealed an order to continue Fall Risk III precautions. Record review of Patient #13's Daily Fall Risk assessment dated [DATE] revealed his score was 15 which put him at High Risk, level III. Further review of the Daily Fall Risk Assessments revealed the following dates the assessments were not done: June - 7th, 8th, 9th, 13th, 14th, 15th, 16th, 26th, 28th, 29th July - 4th, 5th, 6th, 10th, 11th. Record review of Patient 13's Patient's Safety Observation Round Sheets from 5/29/15 to 7/11/15 revealed the Risk Precaution level was not marked or marked as a 1 on the following days: June - 3rd, 4th, 6th, 15th, 23rd, 24th, 30th July - 1st, 2nd, 9th Patient #9 Record review of Patient #9's closed medical record revealed she was admitted on [DATE] for Bipolar disorder. Record review of Patient #9's Fall Risk Assessment and Safety Measures sheet dated 5/5/15 revealed a risk score total of 8. The patient was scored 1 for age, 1 for mental status, and 8 for medications for a total of 10. That put the patient at a moderate fall risk, level II. Record review of Patient 9's Patient's Safety Observation Round Sheets revealed from 5/5/15 to 5/13/15 the patients Fall Precaution was circled level I. Record review of Patient #9's Nurses' Notes revealed she fell on [DATE]. On 5/14/15 she was admitted to the hospital for Altered Mental Status and renal failure. Patient #10 Record review of Patient #10's closed medical record revealed he was admitted on [DATE] with diagnoses of Bipolar Disorder with recent manic psychosis. He was discharged on [DATE]. Record review of Patient #10's Fall Risk Assessment and Safety Measures sheet dated 3/4/15 revealed a risk score of 2 which was a low risk for falls. Record review of Patient #10's Nurses' Notes dated 3/10/15 revealed he was found on the floor shaking. Record review of the Patient's Physician's Orders from 3/12/15 to 3/17/15 revealed orders for Fall Risk III precautions. Record review of Patient #10's Daily Fall Risk assessment dated [DATE] revealed his risk score was 11. Further review of the Daily Assessment sheets revealed they were not done on 3/15, 3/16 or 3/17/15. Record review of Patient 10's Patient's Safety Observation Round Sheets revealed the Fall Precaution was circled I on 3/11 and 3/13/15. On 3/17/15 the Fall Precaution was not marked. Record review of Patient #10's Master Treatment Plan dated 3/4/15 revealed it was not updated for Fall Risk. Patient #11 Record review of Patient #11's closed medical record revealed she was admitted on [DATE] with recurrent depression and psychosis. She was discharged on [DATE]. Record review of Patient #11's Fall Risk Assessment and Safety Measures sheet dated 3/16/15 revealed a risk score of 8 which was moderate risk, level II. Record review of Patient #11's Patient's Safety Observation Round Sheets revealed the Fall Precaution was circled I on 3/16. On 3/17/15 the Fall Precaution was not marked. Record review of the Patient's Nurses' Notes dated 3/16/15 revealed the Fall Precaution was not marked. On 3/17/15 it was circled I. On 3/18/15 Patient #11 fell in the shower. Patient #12 Record review of Patient #12's closed medical record revealed he was admitted on [DATE] for psychosis. He was discharged on [DATE]. Record review of Patient #12's Fall Risk Assessment and Safety Measures sheet dated 4/29/15 revealed a risk score of 10 which was moderate risk, level II. Further review of Patient #12's medical record revealed a Daily Fall Risk assessment dated [DATE] with a risk score of 14. The patient had loss of balance and a poor gait. This assessment placed the Patient at high risk, level III. Record review of Patient #11's Patient's Safety Observation Round Sheets revealed the Fall Precaution was left blank on 4/20 and 4/28/15. On 4/21/15 the risk was circled I. Record review of the Patient's Nurses' Notes revealed the Fall Precaution was marked I on 4/21 and 4/28/15. On 4/28/15 there was a note the Patient's roommate reported the patient fell in the shower. During an interview on 7/22/15 at 12:00 p.m. with RN Charge Nurse #60, he was asked how he found information for filling out the Fall Risk Assessment. He said he would call the family if he got consent from the patient. He could look at previous admission and he could look at the Part I Medical Screening. He said the night nurse got the papers ready for the morning shift. They would circle any precautions the patient was on. He said the day nurse was also responsible for making sure the information was correct and to check for any changes. During an interview on 7/22/15 at 12:10 p.m. with RN Charge Nurse #59, she was asked how she found her information for filling out the Fall Risk Assessment. She said she asked the patient and double checked the admission records. She said she also did her own assessments. She said she would look on the Mode of Transfer sheet. She said she could also look at the Part I, Medical Screen for information about the patient. RN #59 was asked who was responsible for filling out the daily Nurses' Note for precautions and the Patient's Safety Observation Round Sheets. She said the night shift RNs printed out the sheets and filled in the precaution portion. She said the day nurses were responsible for updating the forms and making sure the Round sheets were correct. She said the RNs were also responsible for filling out the daily fall assessments for patients at Risk III. Interview on 7/22/15 at 12:20 p.m. with CNO #51, she said the RNs verify the sheets in the morning. She said the corporation wants the nurses to provide oversight two times per shift. She said one time at the first of the shift and then randomly for the second time. The RN was to check for accuracy of the precautions, effective hand off information and effective monitoring. At 12:25 p.m. the CNO was shown all the above information for the seven patients identified with incorrect or incomplete information for Fall Risks. She looked through each chart and verified the information was not present or was inaccurate. Further interview on 7/22/15 at 1:50 p.m. CNO #51 said the facility identified falls as a problem and instituted the current Fall Risk Assessment about 1 year ago. She said the facility staff were trained on the new procedure. She said the facility had a large turnover of staff and they had not had any recent training on the Fall Risk Assessment. |
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| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a registered nurse (RN) evaluated the fall risk for 7 of 11 patients (#'s 5, 3, 13, 10, 9, 11, and 12) reviewed to ensure the assessments were complete and accurate as evidenced by the following: -Patient #5 was not assessed correctly for Risk of Falls -One patient's (#10) MTP (Master Treatment Plan) was not updated after his fall. -Patient #13 and #12's Daily Fall Risk Assessment was not completed twice a day after falls as per the facility's Policy and Procedure. -Patients' #'s 3, 13, 9, 10, 11 and 12 assessments as Moderate Risk, Level II or High Risk, Level III for falls were not consistently noted in the daily Nurses' Notes or on the Patient's Safety Observation Round Sheets. The areas were left blank or noted at a lower level. Patients 13, 9, 10, 11 and 12 fell during their stay at the facility. Findings Include: Patient #5 Record review of Patient #5's active medical record revealed he was a [AGE] year old male admitted on [DATE] with suicidal ideation with audio/visual hallucinations and depression. Record review of Patient #5's medical record revealed a bright green sheet labeled "Hand-Off Communication dated 7/14/15 at 5:25 p.m. that noted at Fall Risk that the patient had a history of falls with one dated 7/10/15. There was a Part I Medical Screening Evaluation dated 7/14/15 under History of Fall? that circled "Yes" and noted the patient fell on [DATE] at the hospital. Record review of Patient #5's Fall Risk Assessment and Safety Measures sheet dated 7/14/15 revealed he scored a 3, all in Medications. The fall risk levels were as follows: Score 7-10 = Moderate Risk - Fall Risk level II Score 11+ = High risk = Fall Risk level III The patient was not considered a fall risk. There was a section on the form for MOBILITY with one criteria for History of Falls within 4 weeks Prior to Admission. That would have scored 7 points alone and made the patient's total score 10. The patient would have been at Moderate Risk for falls at a level II. Record review of the facility Daily Census Report for Unit 4 General Adult unit dated 7/21/15 showed Patient #5's Fall Risk was a level 1 and he was independent for ADLs (Activities of Daily Living). Review of Patient 5's Patient's Safety Observation Round Sheets revealed the Patient was noted to be independent and at Risk level 1. Interview on 7/21/15 at 1:00 p.m. with MHT (Mental Health Technician) #55, he said the Fall Risk was at a I, II or III. A one meant the patient had a steady gait, a 2 meant an unsteady gait, and a 3 was the patient used a wheelchair or a walker. He said if the patient was at risk II or III he would have to stand closer to the patient if they left the unit. He said the risk level was on his monitoring sheet and on the marker board at the nurses' station. He said he would also find out about patients during the morning report. Interview on 7/21/15 at 1:10 p.m. with CNO (Chief Nursing Officer) #51, she said Fall Risk I needed to be removed from the form. She said the Risk Assessment used to be 1,2,3, but now it is Moderate Risk/level II or High Risk/level III. She was asked what was done differently for patients on moderate or high risk. She said the MHTs would monitor the patient more closely, the staff would give the patient a bell to use at the bedside for assistance, and the facility would try to have the patient moved closer to the Nurses' Station. She said if the patient was cognitively impaired they would put the patient on one to one monitoring. She said the patient might be put on a mattress in the day room to sleep at night if they could not be in a room close to the Nurses' Station. She said the nurses used a Daily Fall assessment sheet for all patients at high risk for falls. She said Patient #5 should be Moderate Risk - Level II precautions. She said the nurse missed the information about his prior fall. The CNO said the Part 1 Medical Screening sheet was filled out by the triage nurse in the triage area prior to admission to the unit. Patient #3 Record review of Patient #3's active medical record revealed she was a [AGE] year old female admitted on [DATE] with suicidal ideation. Record review of Patient #3's Fall Risk Assessment and Safety Measures sheet dated 7/20/15 revealed an assessment score of 9 which was Moderate Risk, level II. Record review of the Unit 4 Daily Census Report revealed Patient #3 was fall risk II. Interview on 7/21/15 at 1:00 p.m. with MHT #55, he said Patient #3 was at fall risk I. He showed the monitoring sheet for Patient #3 and risk I was circled. Patient #13 Record review of Patient #13's closed medical record revealed he was a [AGE] year old male admitted on [DATE] with an exacerbation of paranoid Schizophrenia. Record review of Patient #13's Fall Risk Assessment and Safety Measures sheet dated 7/27/15 revealed a risk score of 6 which was a low risk for falls. Record review of Patient #13's Nurses' Notes dated 5/29/15 revealed he tripped on the leg of the couch and fell . Review of the patient's Nurses' Notes dated 6/15/15 revealed he fell in the shower. Further review of the Nurses' Notes from 5/29/15 to discharge on 7/11/15 revealed no documentation of the fall precautions for the following dates: May - 31st June - 1st, 2nd, 6th, 8th, 9th, 10th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, 21st, 22nd, 23rd, 24th On the following dates the fall precautions were either marked as a I or II: June - 25th, 27th, 30th July - 1st, 2nd, 3rd, 5th, 7th, 9th Record review of Patient #13's Physician's Orders from 5/29/15 to 7/11/15 revealed an order to continue Fall Risk III precautions. Record review of Patient #13's Daily Fall Risk assessment dated [DATE] revealed his score was 15 which put him at High Risk, level III. Further review of the Daily Fall Risk Assessments revealed the following dates the assessments were not done: June - 7th, 8th, 9th, 13th, 14th, 15th, 16th, 26th, 28th, 29th July - 4th, 5th, 6th, 10th, 11th. Record review of Patient 13's Patient's Safety Observation Round Sheets from 5/29/15 to 7/11/15 revealed the Risk Precaution level was not marked or marked as a 1 on the following days: June - 3rd, 4th, 6th, 15th, 23rd, 24th, 30th July - 1st, 2nd, 9th Patient #10 Record review of Patient #10's closed medical record revealed he was admitted on [DATE] with diagnoses of Bipolar Disorder with recent manic psychosis. He was discharged on [DATE]. Record review of Patient #10's Fall Risk Assessment and Safety Measures sheet dated 3/4/15 revealed a risk score of 2 which was a low risk for falls. Record review of Patient #10's Nurses' Notes dated 3/10/15 revealed he was found on the floor shaking. Record review of the Patient's Physician's Orders from 3/12/15 to 3/17/15 revealed orders for Fall Risk III precautions. Record review of Patient #10's Daily Fall Risk assessment dated [DATE] revealed his risk score was 11. Further review of the Daily Assessment sheets revealed they were not done on 3/15, 3/16 or 3/17/15. Record review of Patient 10's Patient's Safety Observation Round Sheets revealed the Fall Precaution was circled I on 3/11 and 3/13/15. On 3/17/15 the Fall Precaution was not marked. Record review of Patient #10's Master Treatment Plan dated 3/4/15 revealed it was not updated for Fall Risk. Patient #9 Record review of Patient #9's closed medical record revealed she was admitted on [DATE] for Bipolar disorder. Record review of Patient #9's Fall Risk Assessment and Safety Measures sheet dated 5/5/15 revealed a risk score total of 8. The patient was scored 1 for age, 1 for mental status, and 8 for medications for a total of 10. That put the patient at a moderate fall risk, level II. Record review of Patient 9's Patient's Safety Observation Round Sheets revealed from 5/5/15 to 5/13/15 the patients Fall Precaution was circled level I. Record review of Patient #9's Nurses' Notes revealed she fell on [DATE]. On 5/14/15 she was admitted to the hospital for Altered Mental Status and renal failure. Patient #11 Record review of Patient #11's closed medical record revealed she was admitted on [DATE] with recurrent depression and psychosis. She was discharged on [DATE]. Record review of Patient #11's Fall Risk Assessment and Safety Measures sheet dated 3/16/15 revealed a risk score of 8 which was moderate risk, level II. Record review of Patient #11's Patient's Safety Observation Round Sheets revealed the Fall Precaution was circled I on 3/16. On 3/17/15 the Fall Precaution was not marked. Record review of the Patient's Nurses' Notes dated 3/16/15 revealed the Fall Precaution was not marked. On 3/17/15 it was circled I. On 3/18/15 Patient #11 fell in the shower. Patient #12 Record review of Patient #12's closed medical record revealed he was admitted on [DATE] for psychosis. He was discharged on [DATE]. Record review of Patient #12's Fall Risk Assessment and Safety Measures sheet dated 4/29/15 revealed a risk score of 10 which was moderate risk, level II. Further review of Patient #12's medical record revealed a Daily Fall Risk assessment dated [DATE] with a risk score of 14. The patient had loss of balance and a poor gait. This assessment placed the Patient at high risk, level III. Further review of the Assessments revealed there were none for 4/28 and 4/29/15. Record review of Patient #12's Patient's Safety Observation Round Sheets revealed the Fall Precaution was left blank on 4/20 and 4/28/15. On 4/21/15 the risk was circled I. Record review of the Patient's Nurses' Notes revealed the Fall Precaution was marked I on 4/21 (it should have been level II) and 4/28/15 (it should have been level III). On 4/28/15 there was a note the Patient's roommate reported the patient fell in the shower. During an interview on 7/22/15 at 12:00 p.m. with RN Charge Nurse #60, he was asked how he found information for filling out the Fall Risk Assessment. He said he would call the family if he got consent from the patient. He could look at previous admission and he could look at the Part I Medical Screening. He said the night nurse got the papers ready for the morning shift. They would circle any precautions the patient was on. He said the day nurse was also responsible for making sure the information was correct and to check for any changes. During an interview on 7/22/15 at 12:10 p.m. with RN Charge Nurse #59, she was asked how she found her information for filling out the Fall Risk Assessment. She said she asked the patient and double checked the admission records. She said she also did her own assessments. She said she would look on the Mode of Transfer sheet. She said she could also look at the Part I, Medical Screen for information about the patient. RN #59 was asked who was responsible for filling out the daily Nurses' Note for precautions and the Patient's Safety Observation Round Sheets. She said the night shift RNs printed out the sheets and filled in the precaution portion. She said the day nurses were responsible for updating the forms and making sure the Round sheets were correct. She said the RNs were also responsible for filling out the daily fall assessments for patients at Risk III. Interview on 7/22/15 at 12:20 p.m. with CNO #51, she said the RNs verify the sheets in the morning. She said the corporation wants the nurses to provide oversight two times per shift. She said one time at the first of the shift and then randomly for the second time. The RN was to check for accuracy of the precautions, effective hand off information and effective monitoring. At 12:25 p.m. the CNO was shown all the above information for the seven patients identified with incorrect or incomplete information for Fall Risks. She looked through each chart and verified the information was not present or was inaccurate. Further interview on 7/22/15 at 1:50 p.m. CNO #51 said the facility identified falls as a problem and instituted the current Fall Risk Assessment about 1 year ago. She said the facility staff were trained on the new procedure. She said the facility had a large turnover of staff and they had not had any recent training on the Fall Risk Assessment. Record review of the facility's Policy and Procedure for Fall Prevention & Reduction dated 4/27/93 and revised on 1/11/15 revealed the following: "Purpose 1. To protect patients and promote patient safety. 2. To effectively identify and interne (sic) with patients that are at risk for falling. 3. To establish a mechanism to effectively identify and intervene with adult patients that have a potential risk for falls by establishing a prescience fall prevention and reduction program... Policy... 8. A risk Assessment will be completed by a Registered Nurse (RN) on all patients at the time of admission to the unit. The RN will be responsible for establishing and updating the individual Master Treatment Plan (MTP) related to prevention and safety... 9. All patients will be assessed for risk of falling upon admission and on the daily RN Shift Assessment. Patients identified to be at risk for a fall will be placed on fall precautions accordingly (Moderate Risk Level II or High Risk - Level III) to promote prevention and reduction. Fall Risk Scores are as follows: 7-9 = Moderate Risk Level II and 11 or greater = High risk - Level III Fall 10. Patients who sustain a fall well be reassessed at the time of fall and immediately placed on the High Risk - Level III category and an MTP for Falls or an update. All subsequent falls will require a reassessment and an MTP update. Interventions will be implemented as indicated. Procedure... a. Fall precautions will be documented on the Patient Safety Observation Round Sheet... c. If the patient's score is 11 or greater, Fall Precautions will be implemented in accordance with the Safety Observation Precaution Policy. d. If a Fall risk Level III is identified a patient will be placed on Fall Precautions immediately. i. The patient's room assignment will be close to nurses' station when conditions permit ii. A Bell will be provided and patient will be instructed to use the bell to call for staff assistance for ambulation, toileting, and hydration as needed.... 12. Shift Assessment - a. Fall risk will be assessed twice daily and documented on the Daily Nursing Assessment Sheet... c. If a patient's condition changes or at the nurse's discretion Fall Precautions may be initiated by (sic) will require a physician order to discontinue once implemented.... 13. d. Patient will be placed on High Risk - Level III Fall Precautions, a Daily Fall Risk Assessment will be initiated and completed daily until patient scores 10 or below. Patient safety measures will be modified and immediately implemented in accordance with the Fall Risk Assessment and documented in the MTP." |
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