HospitalInspections.org

Based on observation, document review, and interview, it was determined that for 3 of 16 (Pt. #2, Pt. #3, and Pt. #4) reviewed for high fall-risk, the hospital failed to ensure that fall precautions were maintained.

Findings include:

1. On 02/15/2024 between 11:15 AM and 12:45 PM, an observational tour of West-2 (medical-surgical/observation unit) was conducted.

- West-3 has a capacity of twenty-nine (29) beds with current census of twenty-five (25) patients. Staffing included, six (6) registered nurses, a charge nurse, four (4) patient care technicians, and one (1) unit secretary, staffing was adequate per staffing matrix. All patients on the census were assessed for fall precautions on admission and every shift. There was a total of eight (8) patients with a medium fall risk score and sixteen (16) patients with a high fall risk score. All the rooms had a fall sign posted on the doors, all patients had a yellow wrist band and yellow non-slip socks. During the tour three patients (Pt. #2, Pt. #3, and Pt. #4) with high risk fall score did not have the bed alarm set at Zone 2, all three patients had their call light within reach.

2. On 02/15/2024, the hospital's policy titled, "Adult Patients Falls-Prevention and Intervention" (revised 11/01/2023) was reviewed and required, " ... At Risk for Falls or Falls Related Injury: any patient that is asssesed to have a Morse Fall Score (MFS) greater than 45 ... Risk for Falls Interventions ... Fall risk signage ... bed/chair exit alarms ... Teammates will complete the environmental safety measures maintained and patient specific safety measures in use on patient care flowsheet in EPIC (patient care documentation system).

3. On 02/15/2024, the hospital provided manufacturer's instructions for the "Chaperone Bed Exit Alarm" (undated). The instructions included, " ... For patients who are a fall risk, Zone 2 (the middle zone of the bed; for patients who should not significantly change their position but will move arms and legs) should be used."

4. On 02/15/2024, the clinical record for Pt. #2 was reviewed. Pt. #2 was admitted on 02/06/2024, with a diagnosis of Obstructive Chronic Bronchitis. The Morse Fall Score (MFS) for 02/15/2024 was 70 (45 or greater-high).

5. On 02/15/2024, the clinical record for Pt. #3 was reviewed. Pt. #3 was admitted on 02/14/2024, with a diagnosis of Acute Kidney Injury. The MFS for 02/15/20024 was 110 (high).

6. On 02/15/2024, the clinical record for Pt. #4 was reviewed. Pt. #5 was admitted on 02/13/2024, with a diagnosis of Chest Pain. The MFS for 02/15/20024 was 75 (high).

7. On 02/15/2024, at approximately 11:45 AM, an interview was conducted with the Unit Manager (E #4). E#4 stated that patients that are a fall risk should have their bed alarm set to Zone 2. Zone 2 is the setting in which an audible alarm will be activated when the patient's torso is off the bed. E #4 confirmed that the beds for (Pt. #2, Pt. #3, and Pt. #4) were not set at Zone 2.

8. On 02/15/2024 at 2:35 PM, an interview was conducted with the Charge Nurse (West-2/E #3). E #3 stated that all patients on fall precautions have to have the bed alarm set at Zone 2. The nurses should look at the setting at start of their shift to make sure the alarm is set at the appropriate setting.