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GRAND ITASCA CLINIC AND HOSPITAL 1601 GOLF COURSE ROAD GRAND RAPIDS, MN 55744 May 7, 2013
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on documentation review and interviews, the hospital failed to supervise and evaluate the patient care needs and response to interventions when 1 of 5 patients (Patient 1), identified as a high risk for falls, fell after being left unattended in the bathroom and sustained a head injury. Findings include:

Patient #1's medical record was reviewed and noted the following: Patient 1 was admitted to the hospital after sustaining a severe stroke. The patient had residual left hemiparesis. The fall risk assessment dated , 3/17/13, indicated the patient was 7, a high risk for falls. The flow sheet data of high risk fall interventions implemented dated 3/18/13 at 12:48 a.m. noted "Communicate fall risk during report and during all hand-off communication." There was no notation that staff should not leave the patient unattended.

Progress notes dated 3/18/13 at 10:03 a.m. established the staff assisted the patient to the toilet. The patient lost her balance when trying to pull the call light string and fell to the floor landing mainly on the left side at 7:25 a.m. The patient sustained a large "goose egg" on her left her forehead and bruise on the left shoulder. The patient complained of a headache and neck pain which were present prior to the fall. Patient #1's medical record included a report of a CT of the brain, dated 2/21/13, prior to this fall which indicated: "No acute intracranial process is appreciated."
CT of the head results dated 3/20/13, after the fall, revealed: "Clinical History: [AGE] year old female with recent fall....CRITICAL FINDING Large Right fronto-temporal intraparenchymal hemorrhage with moderate edema...." An interview was conducted on 5/7/13 at 10:07 a.m. with Employee O/nursing assistant who stated no information that the patient was a high fall risk was communicated during morning report. Staff stated they assisted the patient to the bathroom. The patient was unattended in the bathroom and staff left the patient's room. Employee O stated he was not aware until later that day that the patient was a fall risk.

An interview was conducted on 5/7/13 at 1:55 p.m. with Employee N/nurse who stated no information that the patient was a high fall risk was communicated during morning report. Staff assisted the patient to the bathroom and then left after reminding the patient to use the call light for assistance. The staff left the patient's room. Employee N verified that Patient 1 had been assessed as a fall risk and probably should not have been left alone in the bathroom. Review of the Falls Prevention policy and procedure dated 3/12 noted, "Interventions for High Fall Risk Patients: Stay in bathroom with patient." The hospital staff failed to be aware the patient was at high risk for a fall and failed to stay in the bathroom with Patient 1, resulting in the patient falling and sustaining a intracranial bleed.