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Based on Fall Prevention Policy and Procedures, record review and staff interview, the hospital failed to document and assess a fall for Patient #1, 1 of 3 sampled patients.

The findings include:

Record review for Patient #1 revealed a 2/25/2019 11:44 PM History and Physical for an Orthopedic Surgery Consult for a femur fracture. This was an 8-year-old male who had a fall on 2/25/2019 while riding his razor scooter. He had immediate onset of pain in right thigh and was unable to bear weight. His pain was 6 out of 10, worse with movement, and relieved by rest. Imaging showed right mid-shaft femur fracture, long spiral, mild displacement and shortening. The patient underwent Open Reduction and Internal Fixation (ORIF) with sub-muscular plate on 2/26/2019. The goal was to discharge once pain was controlled and cleared by Physical Therapy.

On 2/27/2019 at 7:45 AM, Nursing Notes (Employee A) revealed patient was fearful of using walker, but once up, he did great. Physical Therapy stated he was good to go home. Mother wanted her son to practice the walker once more before discharge to make sure he was comfortable with it. Patient refused most of day. Once he did get up and use it, he screamed very loudly and only wanted to use the wheelchair. He was crying down the hallway, "I just want to die." Employee A reached out to the physician and discussed the patient's reluctance to use the walker, and that he might be discharged that night. The patient did ambulate to the Playroom later, and then felt more confident to go home. Employee A discussed discharge plan with the oncoming nurse, who agreed to do the discharge for Patient #1.

The next Nursing Interdisciplinary Note was written on 2/27/2019 at 7:47 PM. Patient ambulated around Unit upon assuming care. Feeling more comfortable with ambulation and Mom eager to go home. Discharge Orders initiated and instructions/education provided; in no acute distress. Will be escorted to care home. Patient #1 was discharged home on 2/27/2019 at 8:15 PM.

Physical Therapy notes (written by Employee B) dated 2/27/2019 at 10:39 AM revealed Patient #1 was s/p right femur fracture and ORIF of femur. Pain level 4 out of 10. Patient required maximum verbal encouragement for mobility. 2/2 fearfulness. There were multiple attempts to ambulate patient with him refusing and screaming. Then the patient ambulated 25 feet with contact guard, faded to stand by assistance given use of rolling walker maintaining toe touch weight bearing of right lower extremity without difficulty. Patient was safe to discharge home with family once Durable Medical Equipment had arrived. Based on the above, evaluation is low complexity. No additional skilled physical therapy indicated at this time.

Employee B (Physical Therapist) was interviewed on 4/3/2019 at 1:30 PM. She stated she worked with Patient #1 with gait training and with using a rolling walker. She saw him post-op and saw he was fearful of using the walker and did not want to participate. Mom encouraged him. Eventually, he did. She had to spend extra time with him. She stated she only worked with him in his room and did not ambulate him down the hall. She was never told that the patient had a fall in the hospital. The patient did return to the hospital on [DATE] for a revision of his ORIF. He apparently had a fall with the Mother. Employee B stated she did not know if the fall occurred while in the hospital or at home. There was no documentation in her notes where the fall occurred.

Employee A was interviewed on 4/3/2019 at 2 PM. She stated she did take care of Patient #1 after his ORIF in February 2019. She stated that she did not actually see the Patient fall, but heard it. She was unsure of the time of the fall. It was some time in the evening of 2/27/2019. Employee A stated she saw the Patient and his Mother ambulating in the hallway and Employee A was sitting at the Nursing Station. Employee A heard a thump and heard Patient #1 say, "I told you Mom." Employee A did confirm that the patient was apprehensive to walk after surgery. He had on a long leg cast, which can be heavy for an 8-year-old. She went over to the patient and saw him lying on the floor. The mother had walked away from him and the Patient might have fallen backwards. Employee A stated she assessed the patient after the fall and notified the Orthopedic Resident. The nurse was asked to show the surveyor documentation of this fall. She stated she did not see anything specifically about the fall or if any follow-up care was done if necessary, to see if he reinjured himself. Employee A stated if there was a fall, that an Incident Report should be completed. Employee A stated that Patient #1 was at risk for falls and had a risk band on. Once a patient is assessed as a fall risk, they continue to be a fall risk until discharge. Patients were assessed every 2 hours. There was documentation that Nursing Assessments were done on 2/27/2019 at 1514 and 1938. However, these assessments did not indicate the fall or any reassessment of the patient's status for injury.

Employee C, the Director of Quality on 4/3/2019 at 2:16 PM confirmed the Nurse did not document the patient's fall nor complete an Incident Report.

Employee E, the System Director, Accreditation and Magnet on 4/3/2019 at 2:17 PM, did state that Employee A did contact the Attending Orthopedic via text messaging system about the patient being anxious going home and that the patient threw himself on the floor and wanting to die. However, this text message was not part of the clinical record.

The facility's Fall Prevention July 2019 Policy defines a fall as "Any sudden, unintentional descent with or without injury to the patient that results in the patient coming to rest on the floor or against some other surface, on another person or object. When the initial fall report is written by the nursing staff, the extent of injury may not yet be known. Hospitals have 24-hours to determine the injury level to allow time waiting for diagnostic test results or consultation reports. Patient safety will be addressed in the Plan of Care; Document Fall Prevention/ Safety Interventions in the patient's medical record every 12-hours, when there is a change in patient condition resulting in a change of fall status, and when there is a change in nursing caregiver. When appropriate, perform post-fall huddle and complete Post-Fall Assessment Tool with available staff to individualize and communicate fall prevention strategies; update the Plan of Care".

Employee F, the Assistant Director of Nursing on 4/3/2019 at 2:20 PM, stated that nurses should be documenting falls whether witnessed or unwitnessed on the Interdisciplinary Note. The nurses should also be filling out an Incident Report. This was not done for Patient #1.

Physician progress notes on 3/12/2019 at 9:57 AM revealed revision ORIF right femur fracture for malunion with bent plate. Patient to remain toe touch weight bearing with walker.