HospitalInspections.org

Based on record review and interview, the hospital failed to provide 1 of 1 patient (Patient #10) care in a safe setting, in that, patient #10 was admitted with multiple physical problems, poor endurance and a history of prior falls at home and at the transferring facility. The patient had two falls during his hospitalization with an incomplete "Post Fall Incident Report Addendum."

Findings:

On review of the patient's mobility assessment of 7/19/2014 on 10/2/2014 at 2:00 PM, "the patient's balance was Sitting: Poor, Dynamic Sitting: Poor; Static standing: Poor; Dynamic standing: Poor; Walk on level surfaces: Moderate Assist; Ambulation Distance: 40 feet with a rolling walker. Patient ambulated in scissoring gait pattern with frequent loss of balance due to weakness."

Review of the patient's medical report from 7/21/2014 on 10/2/2014 at 3:00 PM, included the patient was reaching for his walker to go to the bathroom and fell. The "Post Fall Incident Report Addendum" asked how could the same outcome be avoided in the future? This information was left blank and the category of fall was left blank.

Review of the patient's medical record from 7/23/2014 on 10/2/2014 at 3:30 PM, included the patient failed to call for help to get up from toileting and fell and hit his head. The "Post Fall Incident Report Addendum" asked how could the same outcome be avoided in the future? This information was left blank, category of fall was left blank and the degree of injury was left blank.

During an interview with Staff #1 on October 3, 2014 at 2 PM in the conference room, Staff #1 was asked if she had reviewed the "Post Fall Incident Report Addendum" and she replied, "Yes." When asked if the form was complete and if the nurses had covered the question of how could the same outcome be avoided in the future, she replied, "No."

Based on record review and interview, the hospital failed to implement preventive actions and mechanisms that include feedback and learning throughout the hospital as identified during a 7/22/2014 Quality Council Meeting for 1 of 1 patient (Patient #10) who fell on two separate occasions. Patient #10's second fall occurred on 7/23/2014 after the 7/22/2014 Quality Council Meeting was conducted. The "Post Fall Incident Report Assessment" was not complete and did not provide information needed to track, analyze, and implement preventive actions and mechanisms for feedback and learning and the post fall "huddle" was not initiated.

Findings:

Review of the patient's medical record from 7/21/2014 on 10/2/2014 at 3:00 PM, included the patient was reaching for his walker to go to the bathroom and fell. The "Post Fall Incident Report Addendum" asks how could the same outcome be avoided in the future? This information was left blank and the category of fall was left blank.

Review of the patient's medical record from 7/23/2014 on 10/2/2014 at 3:30 PM, included the patient failed to call for help to get up from toileting and fell and hit his head. The "Post Fall Incident Report Addendum" asks how could the same outcome be avoided in the future? This information was left blank, category of fall was left blank, and degree of injury was left blank.

Review of the 7/22/2014 Quality Council Meeting Minutes on 10/3/2014 in the conference room documented falls as a focus area for 2014. The report stated the facility had 11 falls in April, 9 in May, and 18 in June, 2014. Identified actions included the "Post Fall Incident Report Addendum" and "After Fall Team Huddle" immediately following a fall.

During an interview with Staff #1 on October 3, 2014 at 2 PM in the conference room, Staff #1 was asked if she had reviewed the "Post Fall Incident Report Addendum" and she replied, "Yes." When asked if the form was complete and if the nurses had covered the question of how could the same outcome be avoided in the future, she replied, "No." Staff #1 was asked if the "After Team Huddle" for patient falls had begun, she replied, "No, not yet."