HospitalInspections.org

Based on document review and interview, facility nursing staff failed to implement increased post fall nursing interventions for 1 of 10 medical records reviewed. (P1)

Findings Include:

1. Facility policy titled,"Fall Prevention Program", PolicyStat ID 13554604, last revised 04/2023, indicated under POLICY: It is the policy of the Hospital to assess and appropriately identify patients who are at risk for possible falls while hospitalized. A Fall Prevention Program will be implemented and maintained to assure the safety of all patients admitted to the facility. The program will in inclusive of measures which determine the individual needs of each patient by assessing the risk of falls, and implementation appropriate staff interventions to assure a safe environment is maintained, adequate supervision is provided, and assistive devices are utilized when necessary. All falls occurring during hospitalization will be evaluated to determine the potential causative factors and discern appropriate interventions. PROCEDURE: POST FALL EVALUATION: 1. Each time a patient falls, the patient will be assessed by the nurse directly after the fall and the nurse will notify the provider to obtain any necessary orders.

2. Review of P1's MR (Medical Record) indicated:
a. P1 was admitted to H1 (Psychiatric Hospital) on 5/28/2025. Patient suffered a fall at H1 on 6/3/25 at approximately 8:30 pm. P1 hit his/her head causing an injury with bleeding to the back of the head. P1 required an emergency send out to H2 (Acute Care Hospital) where he/she received two staples as closure for a laceration to the back of the head sustained from the fall. At the time of this fall the patient was on every 5 minute observation precautions and non-skid socks. MR lacked documentation of additional fall precautions initiated/implemented by nursing staff.

b. P1 was medically cleared at H2 and transferred back to H1 at approximately 2:10 am on 6/4/25. While being assisted by H1 staff to bed the patient fell a second time onto his/her bottom. P1 was transferred from unit 400 to unit 100 for the use of a medical bed that was closer to the floor. MR lacked documentation of additional precautions initiated/implemented by nursing staff.

c. P1 suffered a third fall on 6/4/25 at approximately 6:30 am. This fall was unwitnessed by nursing staff. P1 hit his/her head, reopening the stapled laceration, and bleeding was noted from the wound. P1 required an emergency transfer to H2 for assessment and treatment related to the third fall. P1 did not return to H1 after being transferred to H2.

4. Telephone interview on 6/17/25 at approximately 4:28 pm with N1 (Registered Nurse) confirmed after a patient falls the falls protocol would be initiated that includes documenting about the fall, implementing nursing measures as needed, notifying the provider or provider on-call, calling 911 for an emergency send out if needed. Bed alarms can be initiated as a nursing safety measure without a provider order but a 1:1 observation may not.

5. Telephone interview on 6/17/25 at approximately 4:35 pm with MD1 (Medical Doctor) confirmed he/she was the on call provider notified of P1's three falls. MD1 confirmed the nursing staff should follow the post fall protocol/instructions for guidance on implementing nursing measures related to falls. MD1 confirmed no 1:1 level of observation was requested by nursing staff in relation to his/her falls.

6. In interview on 6/17/25 at approximately 4:45 pm with A2 (Risk Management) confirmed no bed alarm was initiated/implemented for P1.