HospitalInspections.org

Based on review of clinical records and interview, it was determined the facility failed to assure the plan of car was updated to reflect the assessed fall risk for 13 (#1-#10, #12, #18 and #20) of 20 (#1-#20) clinical records selected for review. Without an updated plan of care, it could not be assured the goals for patient safety would be met. The failed practice affected 13 patients and had the potential to affect all patients admitted to the facility. The findings are:

A. Clinical record review was conducted on 02/03/12 and 02/06/12 for Patients #1-#20. The "24 Hour Patient Record and Plan of Care" was described 02/03/12 by the CNO (Chief Nursing Officer) as the "Nursing Assessment and the Plan of C are for the patients". Page six of eight of the document listed "Safety: Alarms, Falls, Restraints". The Goal of the care plan section stated "Reduce injury and risk of harm". The Fall Risk Assessment stated "If any of the following is "yes", Enhanced Fall Reduction Strategies" must be implemented". The Instructions stated "Must be verified a minimum of once per shift and prn". The "Enhanced Fall Reduction Strategies" included : all standard fall reduction strategies plus: "Low bed with floor pads, consider a sitter for first 24 hours, Net Bed if appropriate, Use of Bed Alarm".

1. For Patient #1-#10, #12 and closed record #18 and #20, one or more conditions effecting gait was selected "Yes" on the current Plan of Care. The "Enhanced Fall Reduction Strategies" Section was documented as "NA", a line drawn through the Section or it was left blank. Documentation did not reflect the Enhanced Fall Reduction Strategies were implemented or the Care Plan Revised.

2. Review of Patient #20's closed record revealed a fall occurred on 10/04/11 at 1645. Documentation on the "7p-7a" shift on 10/04/11, did not include a revision of the plan of care or completion of the Enhanced Fall Reduction Strategies as a result of the fall.

B. The Policy "Clinical Services Policy and Procedure" was provided on 02/06/12. The policy contained the statement "All patients have Standard Fall Reduction Strategies. Fall Risk High will have Enhanced Precautions Implemented." The policy also stated "Post Fall Assessment and revision of plan of care: For any patient fall regardless of injury, there must be an immediate revision of the plan of care. Enhanced Fall Risk Strategies must be implemented, as the patient by nature of the fall is categorized as High Risk. Previous strategies must be evaluated and a plan developed."

C. In an interview with the Chief Nursing Officer on 02/06/12 at 1500, she confirmed the findings and stated "They are supposed to document Enhanced Fall Reduction Strategies if a yes is selected for Fall Risk Assessment or in the event of a fall. All Standard Fall Reduction Strategies are implemented and the Enhanced Fall Reduction Strategies should have been implemented as well.