HospitalInspections.org

Based on document review, observation and interview, nursing failed to ensure a safe setting for 4 of 9 (#p4, #p6, #p8 and #p9) medical records reviewed of patients assessed as high fall risk.

Findings included:

1. Review of policy Fall Prevention & Management Program stated, "All patients admitted to the inpatient setting will be assessed for fall 'risk' using the Modified Morse Fall Risk on admission, each shift, and change in status of the patient, and prior to patient discharge. Safety devices will be initiated when indicated according to policy as soon as possible once the patient is assessed as being 'at risk' for falling. Standard Fall Prevention Interventions: Interventions suggested for implementation in this procedure include both standard and high risk interventions specific to the patient's fall risk score. High Risk Fall Prevention Interventions: Use for those who score High Risk on the Fall Risk Assessment (>45 on Modified Morse Fall Risk Assessment). Consider use of safety technology for fall prevention: Bed and chair alarm". The policy was last revised December 2014.

2. Review of Bed Alarms policy N-27.00 stated, "Patients at risk for falls will be assessed by a licensed nurse on admission and as needed for use of a bed/chair alarm as part of falls prevention program. Licensed nurse will initiate use of alarm in patient's Potential Injury due to Falls Care Plan." The policy was last revised March 2015.

3. Review of medical records #p4, #p6, #p8 and #p9 indicated all four (4) patients were assessed as High Risk fall precautions:

A. Patient #p4 medical record's Nursing Shift assessment - Flowsheet Detail, dated 4/7/2016, indicated Morse Fall Risk Score totaled 50.0. The medical record lacked documentation that bed and chair alarms were considered for use.

B. Patient #p6 medical record's Nursing Shift assessment - Flowsheet Detail, dated 4/7/2016, indicated Morse Fall Risk Score totaled 60.0. The medical record lacked documentation that bed and chair alarms were considered for use.

C. Patient #p8 medical record's Nursing Shift assessment - Flowsheet Detail, dated 4/7/2016, indicated Morse Fall Risk Score totaled 50.0. The medical record lacked documentation that bed and chair alarms were considered for use.

D. Patient #p9 medical record's Nursing Shift assessment - Flowsheet Detail, dated 4/7/2016, indicated Morse Fall Risk Score totaled 75.0. The medical record lacked documentation that bed and chair alarms were considered for use.

4. Patient #p9 had an incident dated and time of 2/14/2016 at 10:00 PM. The incident report indicated the patient discovered date was on 2/15/2016 at 10:00 PM. The report indicated, "The patient was found on the floor by the nurse." The incident report noted the fall prevention interventions prior to the fall were: frequent visual checks, and call bell in reach. The incident report did not indicate the bed alarm was engaged for patient #p9 that had a fall precaution of high risk.

5. Patient #p9 had a second incident dated and time of 3/12/2016 at 4:30 AM. The incident report indicated, "At 0443 the assigned nurse reported that the patient was found on the floor by another nurse. The nurse stated she did not activate the bed alarm." The incident report noted the fall prevention interventions prior to the fall were: frequent visual checks, call bell in reach, personal items in reach, verbal reminders, ID'd as fall risk, light on in room, and low bed. The incident report did not indicate the bed alarm was engaged for patient #p9 that had a High Risk fall precaution.

6. At 1:40 PM on 4/7/2016, #p6 and #p9's rooms were observed with staff members #3 (CCO), #6 (RN Supervisor) and #5 (Plant Operations). #p6 and #p9's beds were observed with bed alarms that were not on.

7. At 2:45 PM on 4/7/2016, staff member #1 (Director of Quality) indicated all patients of the hospital are assessed as universal fall precaution at a minimum; however, High Risk fall precaution shall be initiated when the assessment requires it.

Based on observation, document review, and interview, the hospital failed to ensure Abbott Nutrition ready-to-hang (RTH) and Hi-Cal Light nutritional supplements were stored properly in the nourishment room and the supply room.

Findings included:

1. Review of Abbott Nutrition ready-to-hang (RTH) and Hi-Cal Light nutritional supplements manufacturer's specification sheet stated, "Several vitamins are light sensitive and degrade with exposure to light. Prolonged exposure to high intensity light sources degrades the vitamins at a faster rate. Store product in the shipper as long as possible or store on covered shelves or in a closed cabinet prior to use."

2. At 2:50 PM on 4/7/2016, the nourishment room was observed storing four assorted Abbott Nutrition ready-to-hang (RTH) and Hi-Cal Light nutritional supplements on the counter that were exposed to the florescent lighting within the room: Jevity 1.5 Cal; Osmolite 1.0 Cal; and 2 Glucerna 1.2 Cal.

3. At 3:10 PM on 4/7/2016, the supply room was observed with a wired shelf storage rack storing approximately 150 assorted nutritional supplements manufactured by Abbott Laboratories. Each individual container was removed from their original carton that they were packed in and displayed on the wired shelving unit. The assorted containers of nutritional supplements product label indicated, "Contains light-sensitive nutrients." The 150 assorted nutritional supplements were observed exposed to the fluorescent lighting within the room.

4. At 3:10 PM on 4/7/2016, staff member #8 (Dietician) indicated the Abbott nutritional supplements that are stored in the store room are not protected from the fluorescent lighting. The staff member indicated he/she instructed the store room clerk that the product should have been stored in the shipping cartons they were received in before they are used for the patient; however, this has not been implemented. The staff member indicated the light intensity degrades the vitamins in the supplements.