HospitalInspections.org

Based on document review and interview, nursing services failed to activate the bed alarm prior to a fall for 2 of 10 high fall risk patients MRs (Medical Records) reviewed (P4, P5).

Findings include:

1. Facility policy titled Fall Risk Assessment and Prevention, Policy Number: 4172.8, Policy Approval Date: 6/18/2025, under Purpose: To reduce and prevent falls within the adult hospital setting. Under Policy: All patients presenting to the hospital will be screened for falls risk by a nurse upon admission. Patients will be rescreened once a shift, when there is a change in the patients' status, following a fall. Interventions for Fall Prevention for all patients: Educate patient and family on falls prevention: (Use of call light for ambulation/toileting, call light within reach, bed in low position, provide non-skid socks, use of bed alarm etc.) If the score deems the patient at risk for falls (Moderate Fall Risk Score 6-13, High Fall Risk >13). If total score deems patient a High Risk Fall >13, place patient on bed alarm.

2. Review of P4 MR indicated P4 was a high-risk for falls with a score of 17.
a. On 7/2/25 nurse note indicated P4 was observed laying on the floor in the bathroom by staff member, patient was assessed for injuries, pain, and stated "I lowered myself to the floor because I needed to use the bathroom and was unable to locate the call light". P4 pulled him/herself along the floor until he/she was able to reach the toilet. P4's vitals were assessed and he/she was assessed for injury. P4 stated I did not hurt myself, I did not fall".
b. Nursing flowsheets lacked documentation of bed alarm turned at the time of patient fall on 7/2/25 at 0315 hours.

3. Review of P5 MR indicated P5 was a high-risk for falls with a score of 14.
a. On 8/21/25 at 0129 hours nurse notes indicated the sitter was standing near P5's doorway stating P5 fell. N3 walked into P5's room, P5 was laying on the floor by the trash can.
b. MR lacked documentation the bed alarm was activated on 8/20/25 at 2020 hours and 2135 hours prior to P5's fall on 8/21/25.

4. In interview on 9/16/25 at approximately 1330 hours with A4 (Nurse Manager), he/she confirmed patients P4 and P5 were a high risk for falls, and P4 and P5's MRs lacked documentation of bed alarms activated per policy prior to the patients' falls.