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Based on clinical record review and staff interview it was determined the hospital staff failed to follow hospital policy in notifying the patient's family and/or physician at the time of a patient fall. This affected 2 of 2 (patient #'s 5 and 6) patients reviewed for falls. The hospital staff also failed to follow the hospital policy for telemetry monitoring and the protocol for Diltiazem. This affected patient #10. The total sample size was eleven.

Findings include:

Review of the clinical record for Patient # 6 was completed on 05/19/10. This patient was admitted to the hospital on 02/04/10 with a diagnosis of pneumonia and a long history of rheumatoid arthritis. On 02/12/10 nursing documented a fall by the patient. An occurrence report, completed by the nurse, on 02/12/10, indicated the patient's family and physician were not notified of the incident because "patient deferred."

The hospital policy entitled, "Fall Prevention Protocol" was reviewed on 05/18/10. Page 4 of the policy discussed the post fall protocol and directed the clinician to communicate with the physician and the family.

Interview with two staff registered nurses, (Staff B and D), on 05/18/10 revealed their response to a patient fall would include notification of the patient's family and physician after an assessment of the patient was completed.

This finding was confirmed with Staff A on 05/19/10 at 9:30 A.M.




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The clinical record review for Patient #5 was completed on 05/19/10. The clinical record revealed the 42-year-old patient was admitted to the facility on 04/20/10. A history and physical dated 04/21/10, stated the patient had diagnoses which included bipolar and chronic drug addiction, pneumonia and empyema (a collection of pus in the space between the lung and the inside of the chest wall). The clinical record lacked a physician's order for an activity level for the patient. A flow sheet dated 05/14/10, for the day shift (7:00 A.M. to 7:00 P.M. indicated the patient was a moderate fall risk for, among other things, occasionally demonstrating unsafe behavior. A nursing note dated 05/14/10 at 3:30 P.M., stated the patient was observed walking in the hallway without assistance. The note stated the patient was told of the importance of asking for assistance prior to ambulation. A flow sheet dated 05/16/10, for the day shift (7:00 A.M. to 7:00 P.M.), indicated the patient was a moderate fall risk due to a balance problem when standing and/or walking and for changes in the patient's gait pattern. The flow sheet stated the patient was to have a chair and bed alarm in place. The flow sheet directed the clinician, following a fall, to take vital signs every 15 minutes until stable. The clinical record review revealed a nursing note dated 05/16/10 at 4:40 P.M. that stated, "(Patient) found kneeling next to bed. Stated she 'fell down while trying to get to walker." The note did not indicate whether the chair or bed alarm had sounded.

A review of an occurrence report dated 05/16/10 for this event stated the physician was notified. It did not say the family was notified.

A review of the nursing notes dated 05/18/10 did not indicate the patient was placed as high risk.

A review of the facility's policy entitled, "Fall Prevention Protocol" and approved on 05/09/07, stated following a fall, the patient's family is to be notified. The policy stated, "Any patient who falls is placed in the high risk level for remainder of the hospital stay.

On 05/18/10 at 3:55 P.M., the surveyor observed the patient's door to have a yellow star.

On 05/18/10 at 3:55 P.M. in an interview, Staff B confirmed the yellow star on the door and said it should be a red star, indicating the patient was a high risk.

On 05/18/10 at 4:30 P.M., in an interview, Staff C stated the patient fell after she got up from a chair and was getting to her walker. She said she had not placed a chair alarm prior to the patient's sitting in said chair. She said she thought she had taken the patient's vital signs, but was unable to locate them in the documentation.

On 05/18/10 at 4:55 P.M., the surveyor and Staff A went to Patient #5's room. The surveyor and Staff A observed the patient in a chair, without any other hospital staff in the room. The surveyor and Staff A confirmed the patient did not have a chair alarm in place. Staff A asked the nursing staff to place one.

On 05/19/10 at 9:50 A.M., in an interview with Staff F and Staff A, they said the clinical record did not need an activity order because the physician ordered physical therapy and occupational therapy to evaluate and treat. They said they expected the nursing staff to reference physical therapy and occupational therapy notes prior to getting a patient up out of bed.



The clinical record review for Patient # 10 was completed on 05/19/10. The patient was admitted to the hospital on 04/17/10. A history and physical, dated 04/18/10 documented the patient had diagnoses that included acute renal failure, chronic renal failure secondary to open heart valve replacement and hypertension.

On 5/17/10 at 11:30 P.M., a nursing note documented the patient had a heart rate of 170 to 180 beats per minute. A physicians's order instructed Cardizem, a medication used to convert the rapid ventricular response of atrial fibrillation, was to be given as an intravenous drip and directed the nurse was to call the physician within one to two hours if the patient did not convert out of atrial fibrillation. The patient was transferred to the intensive care unit at 12:50A.M. The Cardizem intravenous drip at 5 milligrams per hour was started at 12:50A.M.

The Cardizem drip dosage was increased due to continued rapid ventricular response at the following times: 1:50 AM, dosage increased to 7.5 milligrams per hour, the patient's heart rate was between 95 to 111 beats per minute; 2:40 A.M., dosage increased to 10 milligrams per hour, the heart rate remained between 90 to 100 beats per minute range; 3:55 A.M., dosage increased to 12.5 milligrams per hour, heart rate range from 85 to 96 beats per minute.

The clinical record lacked evidence of the measurement of the patient's vital signs except for the pulse rate which was monitored by cardiac telemetry and the documentation of the patient's blood pressure at 3:55 A.M. and at 4:00 A.M. The record lacked documentation of the patient's temperature, respiration rate and blood pressure from 5/17/10 at 10:42 PM until 5/18/10 at 3:55 A.M., when the patient's blood pressure reading was documented.

A review of the facility's policy entitled " Diltiazem/Cardizem Protocol" was reviewed during the morning of 05/19/10 and revealed vital signs are to be monitored and recorded five minutes after the initiation of the intravenous Cardizem, 30 minutes after, one hour after and every hour thereafter.

The Taber's medical dictionary defines vital signs as those physical signs concerning functions essential to life (i.e., pulse, rate of respiration, blood pressure and temperature).

The hospital's policy entitled "Telemetry Cardiac Rhythm Surveillance", reviewed during the morning of 05/19/10, revealed while a patient has cardiac telemetry, the nurse is to document the patient's responses to the interventions implemented.

During an interview on 05/19/10 at 11:30A.M., Staff E confirmed the clinical record lacked evidence of documentation of the patient's response after each time the dosage of the Cardizem was increased.

During an interview on 0/19/10 at 2:30P.M., Staff A was unable to identify documentation in the clinical record as evidence the vital signs had been monitored as required according to the hospital policy for the administration of the intravenous Cardizem.