HospitalInspections.org

Based upon record review and interview, the hospital failed to ensure for 1 of 9 records reviewed (#5), the Registered Nurse conducted a post fall evaluation/assessment and followed established policy and procedure for reporting patient falls. Findings:

Review of patient #5's medical record revealed according to the Nurse Practitioner's notes dated 03/01/24 at 11:06 a.m. she had received a call from the nursing staff that the patient had fallen in the shower and hit her head. Review of the Registered Nurse notes revealed no documentation the patient had fallen and hit her head. There also failed to be documented evidence the Registered Nurse conducted a post fall evaluation/assessment of the patient's condition. The first documentation by the Registered Nurse related to the patient's fall was on 03/01/24 at 11:03 a.m. when the Nurse Practitioner ordered the patient be transferred to an acute care hospital for a Computerized Tomography Scan of the patient's head. Upon return staff were to do neurological checks every two hours on the patient.

Review of the Policy titled "Patient Falls" revealed "If a fall occurs: Assess the patient for injury prior to moving notify physician and notify family member; Document the physical assessment and events in the chart and complete the post-fall assessment in the EMR; Conduct post fall assessment or consider debrief with team members to determine immediate/root cause of the fall within 15 minutes of the fall and plan further interventions; An incident report should be completed and turned in to the quality department."