HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that the fall policy was followed and care plan was implemented for falls as evidenced by failing to provide appropriate interventions for 2 of 5 patients identified at high risk for falls (Patient #1 and #3). As a result of this failure, patient #1 suffered 2 falls, and patient #3 suffered 1 fall.

Findings:

Patient #1

Review of the hospital's policy titled Fall Prevention Program NPSG.9A revealed:
Procedure 4. Safety precautions and fall risk interventions are immediately put into place based on the patients fall risk scale of High, Medium and Low....13. Update the Interdisciplinary plan of care....14.b. Complete an incident report form and send to QM department with the patient's current medication record.

Further review of the Fall Prevention Program policy for Fall Risk Interventions revealed 3 levels of interventions: Low Risk initiate measures 1-5; Medium Risk initiate measures 1-14; and High Risk initiate measures 1-18. Measure #15 stated: Remain with patient when on bedside commode (BSC) or in bathroom.

Review of the medical record for patient #1 revealed an admit date of 10/30/17 with diagnoses including Esophageal Cancer, debility, pneumonia and Alzheimer's dementia. Review of the Admission Nursing Assessment revealed a fall risk assessment score of 8 (moderate) related to risk factors of age, hearing impairment, gait/balance and medications. On 11/01/17, patient #1 was elevated to high risk related to mental status and remained high risk throughout the duration of his stay.

Review of the Interdisciplinary Plan of Care initiated 10/30/17 for Safety r/t: History of falls, High fall risk score, Impaired judgment, Generalized weakness revealed: initiate fall risk prevention measures for recorded score; Offer toileting EACH visit before leaving patient's room.

Review of the Fall Risk Assessment dated 11/12/17 at 7:00pm revealed a score of 14 (high risk).
Review of the Nursing Progress Note dated 11/13/17 at 0405 revealed patient #1 was found sitting on the floor and stated he was "trying to get some water." The nurse explained to the patient that he was NPO (nothing by mouth). No injuries were observed and the patient was assisted back to the bed with the bed alarm turned on.

Review of the incident reports/fall investigations provided revealed no documented evidence that the fall on 11/13/17 was investigated.

Review of the Fall Risk Assessment dated 11/23/17 at 7:00am revealed a score of 20 (high risk).
Review of the Nursing Progress Note dated 11/23/17 at 0930 revealed S3RN was called to the room of patient #1 by S2RN Supervisor, who found the patient lying on the floor by the bedside commode with stool on the floor and his gown. Patient was oriented x 3. He was assessed and put back in bed. A knot was noted to the posterior head. Denied pain.

Review of the Interdisciplinary Plan of Care revealed there was no revision of the care plan after the fall occurred on 11/23/17.

On 02/20/18 at 11:15am, an interview with S3RN revealed that on 11/23/17 at 0930 the CNA had placed patient #1 on the bedside commode, pulled the curtain, and did not have visual contact with him. Patient #1 fell off the bedside commode when he attempted to reach for some bathroom tissue. She confirmed that the CNA was not in the room when she was called by S2RN Supervisor.

On 02/20/18 at 12:20pm, an interview with S2RN Supervisor confirmed that the CNA was not in the room of patient #1 when she came in and found him on the floor on 11/23/17 at 0930. She verified that according to the policy and care plan, a patient who is scored high risk should not be left unattended with toileting. Further interview confirmed that it is the responsibility of the staff nurse to complete an incident report when a patient has a fall and confirmed that she did not receive a fall report from the nurse who documented the fall on 11/13/17 at 0405. She further confirmed that the care plan should have been revised following the fall on 11/23/17.

Patient #3

Review of Patient #3's Fall Risk assessment dated 2/6/18 at 3:40 p.m revealed patient assessed with score of 14 (high risk) for falls.

Review of Patient #3's Plan of Care revealed, in part, the following Problems:
High Risk for Falls related to surgery, no weight bearing left lower extremity, Seizures, Fall on 2/10/18.

Review of Hospital's Report of Patient Fall dated 2/10/18 at 6:45 a.m. revealed, in part, the following: Unassisted, unobserved fall. No injury. Toileting related activity. Balance loss. Patient had been assessed as a fall risk.
Report of Patient Fall narrative revealed, in part, the following: Called in the room per S9 CNA(Certified Nursing Assistant) because patient had fallen in the bathroom. CNA stated he had assisted patient into the bathroom and left the room when the patient was going to sit on the commode.

During an interview on 2/20/18 at 1:45 p.m. S1 Nurse Manager acknowledged leaving a patient unattended on the commode, who was assessed as a high risk for falls, was against the hospital's policy.