HospitalInspections.org

Based on observation and record review the facility failed to ensure nursing supervised and evaluated the nursing care for each patient. Nursing did not maintain safety measures for patients with risk of falls in four (4) out of six (6) patients that were on fall precaution (patient ID # 7, 8, 9,12).

Finding Included:

Four (4) out of five (5) patient (patient ID #7, 8, 9, 12) did not have on yellow colored armband on wrist and non-skid/skid socks as stated in the facility policy.

Observation of patients on the third floor on 10/23/2018 between 1000-1230 showed:

Patient (ID#7) a 83-year old was admitted for acute congestive heart failure and was on fall precaution. She had on yellow socks, but did not have a yellow arm band as an indicator of a fall risk as described in the facility policy.

Patient (ID#8) 35-year old was admitted for colostomy reversal with a history of morbid obesity. He was on fall precaution and did not have on a yellow arm band but was wearing yellow socks.

Patient (ID#9) 61-year old was admitted for chest pain and place on fall precaution. He had yellow socks but no yellow arm band.

Patient (ID# 12) 65-year old admitted for cerebral brain hemorrhage, fall, left sided weakness, brain metastasis. He had no yellow socks or arm band on.

Interview on 10/24/2018 at 1130 with the Director of Patient Care Services, (ID # 67), she stated patients should have a yellow arm band and yellow socks on to indicate the patient is a risk for fails.

Record review of current facility policy "Falls Prevention" revised 04/2017 stated on page 6:
A yellow colored armband placed on the wrist and no slip/skid socks applied to serve as identifiers/preventative measures for the entire
healthcare team.