HospitalInspections.org

Based on document review and interview, nursing services failed to notify family of patients falls for 2 of 10 patient medical records reviewed. (P7, P8)

Findings include:

1. Policy titled Incident Reports, Policy No.: NU.28, Reviews: 12/2023, Page 2, under Taking Action and Completing The Incident Report: The completed incident report reflects documentation that the following actions have occurred: Attending physician notified within 1 hour of incident/injury involving their patient. Family/significant other of patient notified of incident/injury after physician is notified. Forwarded to the charge nurse/DON (Director of Nursing) for review and signature. The incident report narrative must be detailed and should tell the story of the incident to the reader, the narrative should include: who, what, when, where, how. The report should include details explaining what occurred prior to, during, and after the incident.

2. Review of P7 MR (Medical Record) indicated:
On 6/15/25 at 1245 hours Nurse's shift note indicated the patient got up from the chair and was unsteady. Patient began walking, his/her body began to lean to the right, patient stumbled into the wall falling to the floor. Patient landed on his/her right side. The patient had a red bump to right the side of the back of his/her head and complained of soreness to all of his/her body. MR lacked documentation of nursing services notifying family of patient fall

5. Review of P8 MR indicated:
a. On 5/12/25 at 1718 hours indicated patient had a fall near nurse's station witnessed by staff. Patient hit the right side of head with no injury noted. MR lacked documentation of nursing services notifying family of patient fall.

6. In interview on 6/24/25 at 0900 hours with A1 (RN [Registered Nurse], QA [Quality Assurance] Risk IFC [Internal Financial Controls] Manager), he/she confirmed the family was not notified of P8's fall on 5/12/25 and family was not notified of P7's fall on 6/15/25.

Based on document review and interview, nursing services failed to complete Incident reports according to policy in two (2) instances.

Findings include:

1. Policy titled Incident Reports, Policy No.: NU.28, Reviews: 12/2023, Page 2, under Taking Action and Completing The Incident Report: The completed incident report reflects documentation that the following actions have occurred: Attending physician notified within 1 hour of incident/injury involving their patient. Family/significant other of patient notified of incident/injury after physician is notified. Forwarded to the charge nurse/DON (Director of Nursing) for review and signature. The incident report narrative must be detailed and should tell the story of the incident to the reader, the narrative should include: who, what, when, where, how. The report should include details explaining what occurred prior to, during, and after the incident.

2. Review of facility Incident reports from 1/1/25 through 6/23/25 indicated the following incidents related to allegations involving P7:
a. Incident Report Form dated 6/14/25 at 0705 hours indicated patient had a fall, report lacked summary of events, notification of physician, administration, family and nurse's signature.
b. Incident Report Form dated 6/14/25 at 0956 hours indicated patient had a fall, report lacked summary of events, and notification of administration.

3. Review of P7 MR (Medical Record) indicated
a. On 6/14/25 at 0705 hours Nurse's shift note indicated patient was standing at the end of a table with both hands on table, patients legs began to bend, and she fell to the floor landing on his/her right side. Head was not hit.
b. On 6/14/25 at 0956 hours Nurse's shift note indicated Patient was ambulating in common area, he/she began to stumble backwards, fell and hit his/her head with no injuries to head noted. The patient's right elbow had light bleeding from an old, scabbed area.

4. In interview on 6/24/25 at 0900 hours with A1 (RN [Registered Nurse], QA [Quality Assurance] Risk IFC [Internal Financial Controls] Manager), he/she confirmed the family was not notified of P8's fall on 5/12/25, administration was not notified of P7s two falls on 6/14/25 and family was not notified of P7's fall on 6/15/25. A1 also confirmed the incident form requires administration to be notified of a patient fall.