HospitalInspections.org

A. Based on review of Hospital policy, clinical records, and staff interview, it was determined that for 1 of 10 (Pt #1) clinical records reviewed for patients at high risk for falls, the Hospital failed to ensure that the appropriate fall precautions were maintained.

1. The Hospital's policy entitled, "Fall Prevention" (revised 3/12) required, "1. Adult inpatients are assessed on admission, and re-assessed daily, using the Morse Fall Risk Assessment Scale, an evidence based tool ...3. An Individualized Plan of Care for Fall Prevention is developed for inpatients identified as Fall Risk= Morse Fall Risk Score 35 or greater. 4. Orange Fall Risk Armband is placed on patient's right wrist (if possible) to assist in identification of Fall Risk Status...Optional use of Bed Alarm."

2. Pt #1 was a 93 year old male admitted on 4/11/12 with a diagnosis of Acute Mental Status Changes. The clinical record for Pt #1 included a Morse Fall Risk Score of 70 on 4/12/12, and the Plan of Care included that Fall precautions including a bed alarm were in place for Pt #1 from 4/13/12 - 4/17/12. Pt #1 fell on 4/14/12 at 12:45 PM, and the nurse's note dated 4/14/12 at 3:30 PM included, "Patient found on the floor next to the bed...Bed alarm placed back to on..." The clinical record lacked documentation that the bed alarm was on at the time of the fall.

3. The above findings were confirmed with the Director of Quality Resource Management on 3/19/12 at approximately 4:30 PM.


B. Based on review of Hospital's policy, clinical record, occurrence report for a fall, and staff interview, it was determined that for 1 of 1 (Pt #1) patient who had a fall during the hospitalization, the Hospital failed to conduct and document a debriefing and provide staff education as required per the Hospital's policy.

1. The Hospital's policy entitled, "Fall Prevention" (revised 3/12) included, "If Fall/Assisted Fall occurs...A debrief is conducted with unit staff and the Fall Action Lessons Learned Team worksheet completed and given to the unit manager. The information gained from the post-fall huddle is shared with other staff to help prevent recurrence and for staff education."

2. Pt #1 was a 93 year old male admitted on 4/11/12 with a diagnosis of Acute Mental Status Changes. The clinical record for Pt #1 included a Morse Fall Risk Score of 70 on 4/12/12, and the Plan of Care included that Fall precautions including a bed alarm were in place for Pt #1 from 4/13/12 - 4/17/12. Pt #1 fell on 4/14/12 at 12:45 PM, and the nurse's note dated 4/14/12 at 3:30 PM included, "Patient found on the floor next to the bed..."

3. On 4/9/12 at approximately 3:30 PM, the Surveyor requested documentation of the debriefing and staff education following the fall for Pt #1, and was told by the Director of Quality Resource Management that the Hospital does not retain the Fall Action Lessons Learned Team worksheet or documentation of staff education following a fall. Therefore, it could not be determined that this was completed as required per policy.