HospitalInspections.org

Based on document review and interview, the facility failed to ensure nursing staff documented patient falls in the patient medical record for 3 of 6 patients with falls (patients #3, 4 and 5) The facility failed to ensure nursing staff completed a post fall assessment for 4 of 6 patients with falls (patients #1, 3, 4 and 5). The facility failed to ensure nursing staff documented nurse shift assessments each shift for 1 of 10 medical records reviewed (patient #3). The facility failed to ensure nursing staff followed physician orders related to physician notification of falls for 4 of 10 medical records reviewed (patients #1, 2, 4 and 5). The facility failed to ensure nursing staff notified family/power of attorney of a patient fall for 5 of 6 patients with falls (patients #1, 2, 3, 4 and 5).

Findings include:

1. Facility policy titled "Fall Prevention" last reviewed/revised 7/27/20 indicated the following: "I. PURPOSE: The Fall Prevention Policy purpose is to (1) establish a multi-disciplinary approach to fall prevention and implement fall prevention strategies to prevent falls...IV. PROCEDURE FALL RISK ASSESSMENT, SCREENING AND INTERVENTIONS...REQUIRED ACTION...6. Re-Assessments...Assess patient upon initial admission...Every shift assessment...Following a patient fall following a change in patient status/level of care...8. General fall assessments documentation shall be completed in hospital-specific Electronic Medical Record (EMR) system...VI. PROCEDURE FOR RESPONDING TO PATIENT FALLS...1. Responding immediately to any patient fall and/or injury...Notification to physician...patient family..."

2. Facility policy titled "Nursing Documentation/Assessment" last reviewed/revised 9/21/18 indicated the following: "PURPOSE: To ensure consistent and thorough care of each patient through daily documentation of patient's physical assessment...nursing care priorities and interventions...PROCEDURE...A. A new Nursing Shift Assessment will be started at the beginning of each shift...C. Each shift will complete documentation of information, in all areas that pertain to the care of the patient...D. Significant assessment findings, in any area of the assessment, will be documented...4. Variations in patient safety such as falls..."

3. A review of the facility event log for the time period of 7/1/20 through 10/5/20 indicated the following:

a. Patient #1 had a fall on 8/21/20 at 7:20 a.m.
b. Patient #2 had a fall on 9/23/20 at 8:30 p.m.
c. Patient #3 had a fall on 8/25/20 at 4:45 p.m. and at 9:30 p.m.
d. Patient #4 had a fall on 7/19/20 at 5:55 p.m.
e. Patient #5 had a fall on 7/26/20 at 1:15 p.m.

4. Review of patient #1's medical record indicated the following:

(A) The patient was admitted on 8/20/20 at 3:20 p.m.

(B) The patient had the following physician orders:

"...Notify Provider...Falls..." ordered on 8/20/20 at 3:35 p.m.

(C) Patient #1's medical record indicated the patient had a fall on 8/20/20 at 7:20 a.m. The medical record lacked documentation of a complete nurse post fall assessment related to Patient #1's fall on 8/21/20 at 7:20 a.m. The medical record lacked documentation of Physician notification as ordered for a fall for Patient #1's fall on 8/21/20 at 7:20 a.m. The medical record lacked documentation of family notification of a fall for Patient #1 on 8/21/20 at 7:20 a.m.

5. Review of patient #2's medical record indicated the following:

(A) The patient was admitted on 9/14/20 at 5:04 p.m.

(B) The patient had the following physician orders:

"...Notify Provider...Falls..." ordered on 9/14/20 at 6:10 p.m.

(C) Patient #2's medical record indicated the patient had a fall on 9/23/20 at 7:45 p.m. The medical record lacked documentation of Physician notification as ordered for a fall for Patient #2's fall on 9/23/20 at 7:45 p.m. The medical record lacked documentation of family notification of a fall for Patient #2 on 9/23/20 at 7:45 p.m.

6. Review of patient #3's medical record indicated the following:

(A) The patient was admitted on 8/25/20 at 2:10 p.m.

(B) The patient had the following physician orders:

"...Notify Provider...Falls..." ordered on 8/25/20 at 4:25 p.m.

(C) The medical record lacked documentation of Patient #3's fall on 8/25/20 at 4:45 p.m. The medical record lacked documentation of a nurse post fall assessment related to Patient #3's fall on 8/25/20 at 4:45 p.m. The medical record lacked documentation of a nurse shift assessment for the time period of 8/25/20 at 6:00 p.m. to 8/26/20 at 6:00 a.m. The medical record lacked documentation of family notification of a fall for Patient #3 on 8/25/20 at 4:45 p.m. and 9:30 p.m.

7. Review of patient #4's medical record indicated the following:

(A) The patient was admitted on 7/14/20 at 2:25 p.m.

(B) The patient had the following physician orders:

"...Notify Provider...Falls..." ordered on 7/14/20 at 3:17 p.m.

(C) The medical record lacked documentation of Patient #4's fall on 7/19/20 at 5:55 p.m. The medical record lacked documentation of a nurse post fall assessment related to Patient #4's fall on 7/19/20 at 5:55 p.m. The medical record lacked documentation of Physician notification as ordered for a fall for Patient #4's fall on 7/19/20 at 5:55 p.m. The medical record lacked documentation of family notification of a fall for Patient #4 on 7/19/20 at 5:55 p.m.

8. Review of patient #5's medical record indicated the following:

(A) The patient was admitted on 7/15/20 at 5:30 p.m.

(B) The patient had the following physician orders:

"...Notify Provider...Falls..." ordered on 7/15/20 at 7:43 p.m.

(C) The medical record lacked documentation of Patient #5's fall on 7/26/20 at 1:15 p.m. The medical record lacked documentation of a complete nurse post fall assessment related to Patient #5's fall on 7/26/20 at 1:15 p.m. The medical record lacked documentation of Physician notification as ordered for a fall for Patient #5's fall on 7/26/20 at 1:15 p.m. The medical record lacked documentation of family notification of a fall for Patient #5 on 7/26/20 at 1:15 p.m.

9. During an interview with A3 (Director of Quality/Risk) and A6 (Chief Nursing Officer) on 10/6/20 at 4:45 p.m., they both verified that a post fall assessment should be completed with each fall, the physician and family should also be notified of the fall. A6 verified that a nurse shift assessment should be completed each shift on patients.

10. During an interview with A5 (Network Health Information Management Manager) on 10/7/20 at 2:45 p.m., he/she verified the medical record information for Patient's #1, 2, 3, 4 and 5.