HospitalInspections.org

Based on record review and interviews the hospital failed to ensure the evaluation of patient care needs and health status in 1 out of 10 records reviewed (Pt #1).

Review of the Fall Prevention Policy revised 11/2010, by surveyor #29972 on 12/12/11, reveals the following:

Definition of fall: A sudden unanticipated change in body position in a downward direction that may or may not result in a physical injury. This definition does include an assisted lowering of a patient to a chair or the floor.

Policy:
1. All newly admitted patients will be screened on admission by a nurse for risk of fall, and appropriate fall precaution interventions will be initiated at that time.
2. The Fall Risk Identification Tool or Electronic Medical Record Fall/Risk Assessment will be utilized in the admission process and discussed thereafter as part of the Interdisciplinary Team Conference.
3. Patients will subsequently be re-assessed for falls at change of condition and/or change in medications.
4. All falls will be investigated using the Fall Investigation Worksheet.
Procedure:
1. The standard fall prevention interventions will be followed on all patients as follows
a. The patient ' s bed is kept in lowest position whenever unattended by hospital personnel.
b. The call light will be kept within reach at all times whether the patient is in bed or up in a chair.
c. All patients will instructed to call for assistance as appropriate
2. A Score of >10 = At Risk. Those patients identified as being " at risk " for falls will have additional interventions added to their plan of care in an effort to prevent falls. The At Risk for Fall intervention may include, but are not limited to:
a. Use of a " risk for falls " sign to communicate risk to all caregivers
b. Use a " remember to call for help " sign posted in patient ' s room to remind patient to call for assistance
c. Use of Bed alarms.
d. Turn bed with one side to the wall and place floor mat along entry/exit side of bed.
Ongoing patient evaluation:
1. Patients identified as " at risk " for falls via the Falls Risk Screening Tool or the Electronic Medical Record Fall/Risk Assessment will have an interdisciplinary care plan initiated by the registered nurse under the heading " potential for self-injury related to risk for falls. " Patient/Family education related to the patient ' s specific risk for fall will be reinforced by the Interdisciplinary Team and documented.
2. Interdisciplinary interventions will be added to the care plan as each discipline identifies specific needs.



Review of pt #1 ' s History and Physical dated 9/30/11, by surveyor #29972 on 12/12/11 beginning at 12:45 pm reveals pt #1 ' s Transfer Diagnoses include: Morbid Obesity, Acute or Chronic Respiratory Failure, and Congestive Heart Failure. Review of Nursing Admission Assessment dated 9/29/11 at 6:18 pm reveals pt #1 ' s weight is 499 pounds and past medical history includes " blindness " and " falls " . " Impaired vision or hearing " is documented under the " Sensory Status " category in the Admission Falls/Risk assessment
and the total fall/risk score is 25.

Review of Physical Therapy note dated 10/6/11 at 8:24 am reveals the following: " seen this am, initially pt reluctant to participate with c/o fatigue ...Pt attempted to sit-stand x5 reps with upper extremity push off stable surface, however unable to transition to standing safely required maximum assist of 2 sit-stand to wheeled walker.

Review of pt #1 ' s event/incident report dated 10/6/2011 on 12/12/11 beginning at 12:45 revealed the following: Event occurred on 10/6/11 at 4:10 pm--Nurse was assisting patient with a transfer from bed to wheel chair, nurse reported that as patient stood up, he went to the opposite direction and slid slowly to the ground. Per interview with Staff C (Director of Quality) on 12/13/11 at 10:45 am, a Fall Investigation Worksheet was not completed as required per the hospital ' s Fall Prevention Policy.

Nurse did not use 2 staff to assist patient in transfer from sitting to standing as evaluated during physical therapy treatment to ensure a safe transfer.

Review of Nurse Assessments for " Activity Level " dated 10/7/11 at 10:23 am, 10/8/11 at 3:14 pm, and 10/8/11 at 8:16 pm revealed the following documentation: " Mobile with assistance: rolling walker, wheelchair " . No indication in documentation of pt #1 needing 2 staff members to assist with safe ambulation.

During interview by surveyor #29972 on 12/13/11 at 10:20 am with Staff H (Rehabilitation Director), surveyor #29972 asked how therapy staff communicates with nursing staff of a patients change in activity requirements. Staff H stated physical therapy (PT) staff verbally tells nurse of any changes in patient activity requirements and PT documents in the electronic medical record in the PT notes. A Transfer Sheet hangs in the nursing station with every patients activity level, however usually takes a day or two to be updated. Transfer Sheet is not as accurate as the daily physical therapy notes. Staff H is unaware of how often or if nursing staff check physical therapy notes. Staff H stated, " I always tell nurses to treat a patient like a 2 staff transfer until comfortable with a patients transfer needs. "

Per review of nursing assessments 10/6/11-10/8/11 and 10/21/11-10/22/11 there is no assessment or evaluation of pt #1 ' s history of " blindness " . Under the category of " Sensory Status " in the Fall/risk Assessment there is no documentation of any vision impairment for pt #1 during the above dates reviewed. On 10/6/11 at 11:32 am, " No sensory status risk " is documented in the fall/risk assessment. Nursing Care plans reviewed for " Potential for Injury " dated 9/29/11 at 6:23 pm, 10/2/11 1:31 am, 10/3/11 at 4:34 am, 10/18/11 at 3:20 am, do not address specific interventions or evaluation as they relate to pt #1 ' s " blindness " and maintaining patient safety.

The above information is verified in interview with Staff B (CEO) Staff C (Director of Quality), and Staff D (Chief Clinical Officer) on 12/13/11 at 1:30 pm.