HospitalInspections.org

BASED ON observation, record review, and interviews, the facility to ensure all patients recieve care in a safe setting. One of 20 patients (Patient #1) on 2/09/2025 suffered a fall from the crib when the side rail of the crib was left in the down position by the Registered nurse (RN).

FINDINGS

Patient #1 is a 5 year old little girl brought by a family member to the boarder for medical care.

During an observation of Patient #1's diaper change in room 117 on 2/13/2025 at 10:56 AM with Personnel #1: Personnel #7 prepared supplies for the change. Personnel #8 was present. The supplies were placed on the crib mattress. The crib rail was lowered. Patient #1 opened her eyes and moved her mouth spontaneously to touch and throughout care. Patient #1 did not cry but made small little noises. Personnel #7 stayed with Patient #1 at all times. Patient #1 was rolled to see there was no bruising to the hip/thigh/ischial areas. When the diaper change was complete, Personnel #7 propped the patient into a right sided turn with pillows. Once the positioning was complete, Personnel #7 raised the crib side rail. Patient #1 squirmed and tensed/arched her back throughout the change and positioning. Patient #1 squirmed and tensed/arched until she returned unassisted to her back.

During record review and interview on 2/13/2025 at 11:08 AM, Personnel #5 navigated the record and confirmed the findings. The fall and post fall information was documented by the nurse, respiratory therapy, and the physician.

~ History and Physical by Physician #6 noted, "1/21/2025...She did not meet any of the developmental milestones, is unable to sit, stand, or walk, is nonverbal...stiff limbs from contractures, spasticity...incoordination...Physical Exam...extremely underweight and malnourished...atraumatic microcephalic...dysconjugate gaze, does not appear to track...aphasia expressive, aphasia receptive, spastic quadriplegia with limbs held in extension and contractures of all four extremities...a complex medical history including congenital microcephaly, spastic quadriplegia, global development delay, seizure disorder, feeding difficulties with concern for dysphagia and severe malnutrition...Problem List: CP (Cerebral Palsy)/Microcephaly ..."

~ Nurse Notes by Personnel #4 noted, "2/10/2025 7:24 AM...2225 (10:25 PM) upon changing the patient diaper, nurse turn and reach over to grab the patient's diaper bed rail in down position and patient rolled to her left side falling in between bed and seizure padding..."

~ Physician Progress note by Physician #6 noted, "2/10/2025... fell out of bed last night when the side of the crib was left down. Per nurses report she landed on her feet with her legs straight due to chronic hyperextension from her CP (Cerebral palsy/Microcephaly) contractures. Long bone films showed no fractures..."

During an interview on 2/13/2025 at 8:55 AM in the board room, Personnel #3 (Personnel #1 and #2 were present) was conferenced on video via computer. They were asked about the incident. Personnel #3 confirmed and discussed the fall, post fall actions, and the in-process investigation. Personnel #3 stated, "After the fall on South (unit), the doctor came in and assessed the patient. Patient #1 was stable and fine. Skeletal series (x-rays) were completed to make sure. They (staff) said she fell from the crib. Fell on the side. Post assessment was good. No head strike but hip and leg. The post fall assessment, and incident report were completed. We are not completed with the investigation yet."

During a telephone interview on 2/13/2024 ending at 2:24 PM, Personnel #4 stated, "I came back in and started changing her. I realized I had grabbed the smaller size (diaper.) I turned around to get the bigger one on the chair. She (Patient #1) tends to like the left side and had squirmed off to the left. She fell down..."

The facility's 9/19/2022 Patient Rights and Responsibilities Policy required, "Receive physical and emotional care in a safe setting, which includes environmental safety, infection control and access to protective/security services; to the extent the facility can control that environment...Be free of all forms of abuse, neglect, exploitation, and harassment..."

The facility's 2/06/2024 last revised Assessment and Re-assessment Policy required, "The assessment of the patient is an ongoing process from the start of care through discharge. Each patient admitted to Nexus Children's Hospital-Dallas (NCHD) shall receive a complete assessment by a qualified individual so that a plan of care may be developed to best meet the needs of the patient..."

The facility's 6/19/2023 Fall Prevention Policy required, "identify patients who are at risk for falling and to outline strategies used to develop patient specific or individualized plans of care to reduce falls and fall-related injuries...Beds will be in low position with brakes on unless treatment needs require otherwise. After procedures, the bed will be returned to the low position...Assess your patient ' s need for 1:1 supervision...Consider fall prevention in nursing care plan...Modify patient's plan of care based on risk factors leading to fall..."

BASED ON observation, record review, and interviews, the facility registered nurse (RN) failed to supervise the nursing care of Patient #1 on 2/09/2025 in accordance with the patient's needs. Patient #1 suffered a fall from the crib when the siderail of the crib was left in the down position.

FINDINGS

Patient #1 is a 5 year old little girl brought by a family member to the boarder for medical care.

During an observation of Patient #1's diaper change in room 117 on 2/13/2025 at 10:56 AM with Personnel #1: Personnel #7 prepared supplies for the change. Personnel #8 was present. The supplies were placed on the crib mattress. The crib rail was lowered. Patient #1 opened her eyes and moved her mouth spontaneously to touch and throughout care. Patient #1 did not cry but made small little noises. Personnel #7 stayed with Patient #1 at all times. Patient #1 was rolled to see there was no bruising to the hip/thigh/ischial areas. When the diaper change was complete, Personnel #7 propped the patient into a right sided turn with pillows. Once the positioning was complete, Personnel #7 raised the crib side rail. Patient #1 squirmed and tensed/arched her back throughout the change and positioning. Patient #1 squirmed and tensed/arched until she returned unassisted to her back.

During record review and interview on 2/13/2025 at 11:08 AM, Personnel #5 navigated the record and confirmed the findings. The fall and post fall information was documented by the nurse, respiratory therapy, and the physician.

~ History and Physical by Physician #6 noted, "1/21/2025...She did not meet any of the developmental milestones, is unable to sit, stand, or walk, is nonverbal...stiff limbs from contractures, spasticity...incoordination...Physical Exam...extremely underweight and malnourished...atraumatic microcephalic...dysconjugate gaze, does not appear to track...aphasia expressive, aphasia receptive, spastic quadriplegia with limbs held in extension and contractures of all four extremities...a complex medical history including congenital microcephaly, spastic quadriplegia, global development delay, seizure disorder, feeding difficulties with concern for dysphagia and severe malnutrition...Problem List: CP (Cerebral Palsy)/Microcephaly ..."

~ Nurse Notes by Personnel #4 noted, "2/10/2025 7:24 AM...2225 (10:25 PM) upon changing the patient diaper, nurse turn and reach over to grab the patient's diaper bed rail in down position and patient rolled to her left side falling in between bed and seizure padding..."

~ Physician Progress note by Physician #6 noted, "2/10/2025 17:33 (5:33 PM) fell out of bed last night when the side of the crib was left down. Per nurses report she landed on her feet with her legs straight due to chronic hyperextension from her CP (Cerebral palsy/Microcephaly) contractures. Long bone films showed no fractures..."

During an interview on 2/13/2025 at 8:55 AM in the board room, Personnel #3 (Personnel #1 and #2 were present) was conferenced on video via computer. They were asked about the incident. Personnel #3 confirmed and discussed the fall, post fall actions, and the in-process investigation. Personnel #3 stated, "After the fall on South (unit), the doctor came in and assessed the patient. Patient #1 was stable and fine. Skeletal series (x-rays) were completed to make sure. They (staff) said she fell from the crib. Fell on the side. Post assessment was good. No head strike but hip and leg. The post fall assessment, and incident report were completed. We are not completed with the investigation yet."

During a telephone interview on 2/13/2024 ending at 2:24 PM, Personnel #4 stated, "I came back in and started changing her. I realized I had grabbed the smaller size (diaper.) I turned around to get the bigger one on the chair. She (Patient #1) tends to like the left side and had squirmed off to the left. She fell down..."

The facility's 9/19/2022 Patient Rights and Responsibilities Policy required, "Receive physical and emotional care in a safe setting, which includes environmental safety, infection control and access to protective/security services; to the extent the facility can control that environment...Be free of all forms of abuse, neglect, exploitation, and harassment..."

The facility's 2/06/2024 last revised Assessment and Re-assessment Policy required, "The assessment of the patient is an ongoing process from the start of care through discharge. Each patient admitted to Nexus Children's Hospital-Dallas (NCHD) shall receive a complete assessment by a qualified individual so that a plan of care may be developed to best meet the needs of the patient..."

The facility's 6/19/2023 Fall Prevention Policy required, "identify patients who are at risk for falling and to outline strategies used to develop patient specific or individualized plans of care to reduce falls and fall-related injuries...Beds will be in low position with brakes on unless treatment needs require otherwise. After procedures, the bed will be returned to the low position...Assess your patient ' s need for 1:1 supervision...Consider fall prevention in nursing care plan...Modify patient's plan of care based on risk factors leading to fall..."