HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 (Pt.#21) clinical records reviewed for patients with a fall high risk score and fall precautions, the hospital failed to ensure that the registered nurse ensured that fall precautions were followed to prevent an injury while assisting a patient during a transfer (commode to chair).

Findings include:

1. The hospital's policy titled, "Fall Precautions Procedure" (revised 01/13/2025) was reviewed and required, "Falls can be a source of serious injury to patients ... Routine assessment with the application of patient tailored interventions based on risk identification approach to fall prevention ... Universal precautions are foundational patient safety standards and will be applied to all patients, these include ... use of safety equipment including, mobility aids, as appropriate.

2. The hospital's "Job Description-Registered Nurse" (version date: 04/10/2019) was reviewed and required, " ... Collaborates with patients and ... members of a multidisciplinary team, to ensure optimal patient outcomes and enhancements of the patient experience."

3. The clinical record of Pt.#21 was reviewed on 05/19/2025. Pt.#21 was admitted on 02/06/2025 for an elective surgery and was transferred to a tertiary hospital on 02/19/2025. The clinical record included the following:

-History and Physical, dated 02/06/2025 at 4:24 PM, " ... (Pt.#21) admitted for postoperative management. Procedure per Ortho (orthopedics)was more complex than anticipated, requiring open reduction and internal fixation of the acetabulum (ball and socket joint of femur) due to an intraoperative finding ..."

-Physician Order, dated 02/07/25 at 8:59 AM, "Patient is okay to start PT (Physical Therapy) without hip abduction brace. Patient will be non-weight bearing of left lower extremity ..."

-Fall Risk Assessment flowsheets for 02/07/2025 through 02/19/2025 were reviewed and indicated that the predictive fall risk scores were completed and reviewed by the nurse. (Pt.#21) was stratified as high risk for falls (score from 94 to 100) with the following interventions in place; Patient oriented to room, instructed to call for help, environment free of clutter, Arm Band on, non-skid socks on, call-light within reach, bed in lowest position, bed wheels locked, side rails up x 2, and bed alarm on.

-Nursing Progress Notes (E#5), dated 02/16/2025 at 6:30 PM, "Patient (Pt.#21) was being assisted by the PCT (Patient Care Technician/E#6) from the bedside commode to the chair. Patient stated (Pt. #21) misjudged as (Pt. #21) went to sit down and hit (Pt. #21) left hip on the left side of the recliner chair."

-Orthopedic Progress Note (MD#2), dated 02/17/2025 at 8:40 AM, "(Pt.#21) fell yesterday into (Pt.#21's) chair. I responded immediately with my resident. X-ray and CT (Computed Tomography-images body) show that (Pt.#21) re-fractured their acetabulum and disassociated the prosthetic cup and dislocated the hip ball. (Pt.#21) will need to be transferred to a revision total hip specialist. We are trying to arrange this transfer today. Pain is under control. Neuro (neurologic) status is intact."

4. An interview was conducted with the Orthopedic Surgeon (MD#2) on 05/20/2025 at 8:34 AM. MD #2 stated that the day of the incident (Pt.#21) called MD#2 directly and reported that something was wrong with (Pt.#21's) hip. (Pt.#21) stated that they had fallen into their chair and hit their hip on the armrest. MD#2 stated that (MD#2) immediately sent the Resident to assess (Pt.#21) and ordered a stat (immediate) x-ray. MD#2 stated that (Pt.#21) is a rather large (person) about 6 feet tall and over 250 pounds, and the impact would be high when (Pt. #21) hit armrest. MD#2 stated that (Pt.#21) had to be transferred for revision because the surgery (Pt.#21) required was out of (MD#2's) scope.

5. An interview was conducted with the Patient Care Technician (E#6) 05/20/2025 at 8:48 AM. E#6 stated that E#6 recalls (Pt.#21) and (Pt.#21) was very inpatient and had to be reminded to wait for staff for assistance. On the day that (Pt.#21) sustained the injury (Pt.#21) did not have a gait belt on, and (Pt.#21) was in a hurry to sit on the chair and did not listen to (E#6's/PCT) cues to pivot because (Pt.#21) was not aligned with the chair and plopped down. (Pt.#21) started to scream, E#6 went to get the nurse (E#5) and reported the incident.

6. An interview was conducted with the Registered Nurse (RN/E#5) on 05/20/2025 at 9:45 AM. E#5 stated that, the patient was being transferred from the commode to the recliner. E#5 was not in room but during the incident (Pt.#21) plopped down on chair and was not aligned with chair and hit their left hip. E#5 stated that staff do use gait belts and is not sure if (E#6) used a gait belt during the incident.