HospitalInspections.org

Based on document review and interview, facility failed to keep patient safe from falls for 1 of 10 medical records reviewed (Patient #4).

Findings include:
1. Policy titled "Fall Prevention", Policy Number: NSG 22, last reviewed 01/2023 indicated High-Risk Fall Prevention Interventions are designed to be considered for patient with multiple risk factors, who are scored "high risk" on the modified Morse Fall Scale (score of >45) and have fallen. The healthcare team should tailor the interventions to be patient specific: Place colored non-skid socks; Bed and/or chair alarms, as applicable; Increased observation level of patient; Remain with the patient while toileting.

2. Patient #4 Nurse note dated 10/14/2023 at approximately 1028 hours indicated at 0910 hours CNA (Certified Nursing Assistant) called out from patient #4 room that patient had fallen, nurse entered room and patient was sitting up on floor next to bed outside of bathroom with legs extended in front of him/her and holding self-up with arms and walker next to him/her. Patient reported he/she fell after coming out of the bathroom onto buttocks and complaining of left ankle pain. Provider called and made aware of event and new order to send to ER (Emergency Room) for evaluation and treatment. Nurse spoke with CNA in room assisting patient, he/she reported assisted patient to bathroom with walker and had assisted to toilet and instructed he/her to pull cord when completed and had left door partially open and was checking on him/her while picking up his/her room to provide him/her with privacy per her request and patient is alert and oriented.

3. Incident type-Fall, Report Date-10/14/2023, Time: 0910 hours, Patient #4. CNA called out from patient #4 room, patient had fallen. Nurse went in to the room and patient was sitting up on floor next to the bed outside of bedroom with legs extended in front of her and holding self up with arms and walker next to patient. Patient reported falling after coming out of bathroom onto buttocks and complained of left ankle pain. Provider was called and made aware of event, new order given to send to ER for evaluation and treatment. CNA had assisted patient to bathroom with walker and had assisted to toilet and instructed patient to pull cord when completed and left door partially open and was checking on patient while picking up room to provide privacy per her request. Patient is alert and oriented. Patient did not have on non-skid footwear at time the event occurred.

4. In interview on 11/27/2023 at approximately 1300 hours, A3 (Registered Nurse, Chief Nursing Officer) confirmed Patient #4 was in the restroom while CNA was in patient room packing patient belongings.

5. In interview on 11/27/2023 at approximately 1400 hours with N3 (Registered Nurse), he/she indicated incident report for patient #4 took place on the day patient was being discharged. Patient was in the bathroom while CNA was packing belongings. Patient got up from toilet and with walker left bathroom and fell. N3 indicated patients that are high fall risk and are taken to the restroom by staff, patients are to be within arms reach.