HospitalInspections.org

Based on policy review, medical record review, and interview the hospital failed to ensure patients received care in a safe setting when fall assessments were not completed to determine if 2 of 3 (Patient #1 and 2) sampled patients had increased risks for falls.



The finding include:


1. Review of the hospital policy "FALL REDUCTION PROGRAM" with a revised date 10/17 documented, "...Documentation will be on a 24 Hour Nursing flow Sheet/EMR [electronic medical record]...Universal fall prevention strategies will be implemented for all patients...Post Fall Assessment and Revision to Plan of Care...For any patient fall regardless of injury, there must be an immediate revision of the plan of care...Notify the Physician (with complete assessment information), Administrator on Call, and family...Post fall assessment must include...Vital signs...(complete) location and quality of any pain...Complete neurological and vascular assessment...Patient will be on Neuro-vascular checks and vital signs: every 15 min [minutes] x [times] 4, every hour x 4, every 2 hour x 4, every 4 hours x 3...If patient is on anticoagulants [medications used to prevent blood from clotting] continue Neurovascular checks and vital signs every 4 hours x 48 hours. May use the Neurovascular flowsheet...Incident Report must be completed...Post Fall Debriefing: After each fall the charge nurse will complete a debriefing with those staff responsible for the patient's are at the time of the fall. This will be documented using the debrief form. The debrief form will be completed and forwarded to the CNO [Chief Nursing Officer]/DQM [Director of Quality Management] upon completion..."


2. Medical record review for Patient #1 revealed diagnoses of COVID 19 Infection, Acute Respiratory Failure with Mechanical Ventilation and Tracheostomy, Encephalopathy, Agitated Delirium and Atrial Fibrillation.

A physician's order documented Lovenox 40 miligrams [mg] every 12 hours with a start date of 04/20/2020 at 10:00 PM and a end date of 5/18/2020 at 3:36 PM.

On 5/7/2020 at 3:28 AM Patient #1 was found lying in floor. The 24 Hour Nursing Flowsheet documented postfall assessment for Neuro-vascular checks and vital signs: every 15 min (minutes) x (times) 4, every 1 hour x 4, every 2 hour x 4, every 4 hours x 3, Neurovascular checks and vital signs were documented per policy until the every 4 hours monitoring began. There was no documentation neurovascular checks and vital signs were monitored every 4 hours for 48 hours per hospital policy.

There was no documentation an Incident report or Post Fall Debriefing were completed.

During an interview on 9/15/2020 at 11:15 AM, the Interim CNO confirmed the postfall assessment and vital signs were not documented every 4 hours for 48 hours per hospital policy. The CNO also confirmed there was no documentation an incident report or postfall debriefing were completed.


3. Medical record review for Patient #2 revealed diagnoses of Acute Kidney Failure, Chronic Pancreatitis, Human Immunodeficiency Virus, Chronic Obstructive Pulmonary Disease, Alcoholism, Polysubstance Abuse and Rhabdomyolysis.

A physician's order revealed Eliquis 2.5 mg tablet twice daily with a start date of 04/14/20 at 10:00 PM and a end date of 5/13/20 at 5:05 PM.

On 5/3/2020 at 10:40 AM, Patient #2 was found sitting on the floor sitting. The 24 Hour Nursing Flowsheet documented postfall assessment for Neuro-vascular checks and vital signs: every 15 min x 4, every hour x 4, every 2 hour x 4, every 4 hours x 3. Neurovascular checks and vital signs were documented per policy until the every 4 hours monitoring began. There was no documentation neurovascular checks and vital signs were monitored every 4 hours for 48 hours per hospital policy.

During an interview on 9/16/2020 at 2:22 PM, the Interim CNO confirmed the postfall assessment and vital signs were not documented every 4 hours for 48 hours per hospital policy.