HospitalInspections.org

Based on document review and interview, nursing services failed to follow facility Fall guidelines for fall risk patients in the utilization of patient bed siderails; and failed to accurately document in MR event related to a patient's fall for 1 of 10 patient MR's (Medical Records) reviewed (Patient # 4).

The cumulative effects of these systemic problems resulted in the facility's inability to ensure that quality Nursing Services were provided.

Based on document review and interview, nursing services failed to follow facility Fall guidelines for fall risk patients in the utilization of patient bed siderails; and failed to accurately document in MR event related to a patient's fall for 1 of 10 patient MR's (Medical Records) reviewed (Patient # 4).

Findings include:

1. Facility policy titled: "Risk for Fall and/or Entrapment Guidelines", Policy Stat ID 12014203, indicated on page 2, under PROCEDURE, Action, the following can assist in providing a safe environment for patients; 8th point; ... in locked position, 11th point: Utilize two side rails as applicable for positioning and bed controls, and on page 4, under Fall Actions, if fall should occur, the nurse must take the following actions, 7th point; Document objective findings related to patient fall. Last revised 4/2022.

2. Review of Patient # 4 MR, indicated, the following:
(a). Nursing flowsheets on admission reflected the following:
Morse fall risk - (scores included, but not limited to): on admission = 80 (high risk).
(b). Plan of care on admission reflected patient safety; falls. Fall preventions (included: call light, bed low position, side rails up x [times] 2, staff rounding, non-skid socks, alarms {bed & chair}, fall risk band).
(c). Nurse note on 10/8/2024 at 2:45 am, by N # 20 (RN {Registered Nurse} - 5W-2 - IMCU {Intermediate Care Unit} - staff), reflected nurse was called to patient room where patient was found on the floor nearby bed and commode. Patient was placed on commode and instructed to call for assistance with call light in reach prior to incident. Patient has small laceration to right eyebrow. Patient was assisted back to bed by staff.
(d). MR documentation for fall by nursing staff is not consistent with incident/event report findings.

3. Review of Incident/event report for Patient # 4, dated 10/8/2024 at 2:30 am for an unwitnessed fall (patient's room), indicated the following:
(a). Patient was found on floor near commode. Patient had bruise to right eyebrow.
(b). Event was reviewed by A # 4 (Unit Manager - 5W-2), with additional information. Event date: 10/8/2024 at 2:30 am, for an unwitnessed fall (patient's room), indicated that patient was found on floor near commode - in regards to patient was assisted to BSC (bedside commode), NA (nursing assistant) remained with patient and assisted patient back to bed; bed alarm in place. NA in rush and thought that side rail of bed was latched and left room. Side rail found not to be latched. Patient was found on floor by primary RN.
(c). Incident/event review is not consistent with MR documentation for fall.

4. In interview on 11/12/2024 at approximately 12:00 pm, with A # 4, confirmed the following:
a. Three side rails up, for patients on fall risk; rails would be locked/latched in place.
b. NA assisted patient # 4 from bedside commode back to bed; in incident investigation, NA was unsure if she/he heard click for right side rail once patient was in bed. Call light in place and bed alarm was on.