HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure licensed nurses adhered to policies and procedures of the hospital. This deficient practice was evidenced by the failure to ensure hospital post fall process policy and procedure was implemented by nursing staff for 1 (#3) of 3 (#1 - #3) patients reviewed for falls.
Findings:

Review of the hospital's policy #166 titled "Fall Prevention" with a last revision date of 04/2022, revealed in part,
"I. Purpose: 1. Provide a standard, common definition for falls. 2. Provide evidence-based guidelines for stratification of individualized patient risk for falls. 3. Outline the standard of care for all patients regardless of risk stratification. 4. Outline documentation requirements for nursing. 5. Establish post-fall huddle and Serious Safety Event (SSE) reporting guidelines.
II. Definitions: A patient fall is a sudden, unintentional descent, with or without sustained injury that results in the patient coming to rest on the floor, on or against some other surface, on another person, or on an object. This includes all unassisted and assisted falls regardless of the patient's age or admission status.
III. Policy and Procedures Statements: 1. All patients will be evaluated for fall potential through completion of the appropriate Falls Risk Assessment. This will occur during the admission process; following a change in medical condition and/or level of care; and post fall. 2. Based on the level of fall risk, nursing interventions will be initiated and will be captured on the patient's plan of care. 3. Regardless of risk stratification, standard of care fall prevention elements will be implemented on all patients.
Assessment: 3. Reassessment of fall risk will occur, at minimum, once per shift; following a change in medical condition and/or level of care; and post fall.
Standard of Care: 1. Regardless of risk score or level of stratification, the following will be in place for all patients across the facility.
Documentation: 3. Every patient should have fall prevention measures listed as part of their individualized plan of care.
Post-Fall Process: 2. Notifications of the fall - a. At a minimum, the Attending Physician, Nursing Leader, and patient's legal representative will be notified as soon as possible. b. All notifications will be documented in the EHR. 3. Reporting - a. For each patient fall, the nurse will document in the Post Fall Assessment intervention within the EHR.
Alternative Areas: 1. All Emergency Services areas will follow the above policy details with the exception of assessment timing and frequency. b. Patients presenting to Emergency Services areas, will be assessed for fall risk once per encounter and as needed with any change in patient status. Those patient in an ER Hold status (i.e. admitted patients holding in the ER due to lack of inpatient beds), will follow the assessment expectations for inpatients according to the aforementioned intervals."

Review of the "Manage Refer Contact Notify" report in Patient #3's medical record dated 02/08/2025 at 12:30 PM by S4RN revealed only the provider had been notified of Patient #3's fall. There was no documented record of notification attempts to nursing leadership or Patient #3's legal representative.

Review of the "Post Fall Assessment" in Patient #3's medical record revealed it was created on 02/08/2025 at 8:32 AM by S4RN. No additional changes or modifications were made to the assessment until 02/10/2025 at 9:41 PM when it was completed at the time of the Patient #3's discharge.

On 04/02/2025 at 11:26 AM, an interview was conducted during record review with both S2RMD and S3ERNM. Both confirmed after thorough review of Patient #3's medical record, there were no documented attempts by nursing staff to notify Patient #3's legal representative and nursing leadership and S2RMD and S3ERNM aggreed it should have been documented. S2RMD and S3ERNM also reviewed the "Post Fall Assessment" and confirmed no new interventions were documented after the fall on 02/08/2025 at 12:30 PM and S2RMD and S3ERNM agreed new interventions should have been documented.