Realizing the Importance of Patient Fall Risk Assessments

This claim study focuses on fall risk assessments and documentation issues. Organizations should have a process for post-fall management when a patient fall occurs.

This claim study focuses on fall risk assessments and documentation issues. The case involves an 89-year-old female patient that arrived at the emergency department with complaints of irregular heartbeat and shortness of breath. After the initial examination was completed, she was admitted to telemetry for monitoring. Upon admission, the staff noted her fall risk score as high with a prior history of falls noted in her prior admission records. Bed alarms were put in place, as well as a red flag indicator on the patient’s door. At shift change, the ongoing staff rated the patient’s fall risk assessment as moderate, and contrary to earlier assessment notes, she was noted to have no history of prior falls reported. The staff on duty did not utilize the bed alarm during this shift.

Around 4:00 AM, the patient was found on the floor of the bathroom when she attempted to use the restroom without calling for assistance. Chart notes indicated that a skin tear was noted, and the patient was alert and oriented and assisted back to her bed. When the physician rounded on the patient later that day, there is no mention of the fall in his progress notes. The physician did document evidence of respiratory distress that he felt had not been reported or documented by the nursing staff. The following day the physician rounded again on the patient and found her in moderate respiratory distress with heightened confusion. The patient quickly became unarousable during his exam. A CT was ordered, and a large right-sided subdural hematoma was revealed. At this point, the patient continued to deteriorate and was made a DNR by the family.

Following the CT scan, a late entry was charted by the nurse stating that the patient’s fall had been reported to the physician. The physician disputed that he had ever been advised of the patient’s fall. After meeting with nursing staff and reviewing the basis for the various fall risk assessments, it was determined that given the conflicting testimony of nursing staff and the physician, a compromise settlement should be offered before the claim proceeded to the PCF panel.

Risk Management Notes

Patient falls are a common injury and a major safety concern for hospital patients. Numerous opportunities for improvement exist in the scenario presented above.

As a positive finding, the initial staff assessed the patient for fall risk, and they took preventative strategies upon the patient’s initial admission. The assessment findings do change with the next shift assessment, but the care staff continues to find the patient with a relatively high risk for falls (moderate). Therefore, some level of prevention should still be expected.

Establish Fall Prevention Policies

Every organization should have a patient fall prevention policy in place. Best practice for patient fall prevention includes the use of an evidence-based fall risk assessment that staff should complete upon patient admission, at each shift change, and change in the level of care and condition. Patient fall prevention policies should detail the types of prevention measures that staff should take according to the level of risk identified through the assessment. In addition, the off-going and the ongoing patient care staff should communicate critical assessment findings to ensure the safety of patients using a standardized process for hand-off communication. The fall risk status is critical information that caregivers should communicate at the end of the shift hand-off report.

Utilize Risk Assessment Best Practices

Very often, the risk assessment data in the medical record is not reflected in the patient’s plan of care. Clinical staff must realize the importance of the findings of the risk assessments completed for patients. In this busy world of electronic medical records, sicker patients, and staffing shortages it is easy to quickly progress through the daily assessment just to get the documentation done. Sometimes the interpretation of the assessment findings gets lost in “cyber-space” and never makes its way to the care plan. Staff must realize that there is a purpose for each assessment they complete and that the findings should not be disregarded. Staff must include information from assessments in hand-off communication and relay it to the next caregiver to ensure continuity of care.

Document Patient Care Events

Documentation is such an important function for patient care staff. Documentation can support the care provided, or it can trigger questions regarding the quality of care a patient received. In a perfect world, care staff completes documentation as soon as possible but not in real-time. All documentation should occur before the staff ends their shift. Understandably, staff sometimes needs to enter documentation late, but they should discuss notes entered the next day or beyond with the Risk Manager. Charting policies should be in place that direct staff in the proper way to enter a late note into the medical record. Staff should be following these policies. Caution should be used with late notes as they can reflect negatively on the patient care that occurred and could cause someone reading the late notes to question whether they are a true and accurate reflection of the care provided.

Unfortunately, it appears that the staff, in this case, did not document the adverse event that occurred. Care staff should always document adverse events in the medical record and include only the facts of the event. They should not enter any opinions or assumptions about what happened, nor should they document any admissions of liability made by the caregiver or blamed on the organization. Staff should remember the mnemonic FACT when documenting adverse events: Factual, Accurate, Complete, and Timely.

Organizations should have a process for post-fall management when a patient fall occurs. It should be included in the facility’s fall prevention policy or adverse event reporting policy. The next steps should always include notifying the physician of the event and documenting any orders. The policy should also detail expectations for follow-up assessment of the patient in the event the fall was either unwitnessed or if it is unknown if the patient may have hit their head. Neurological assessment post-fall is critical when the fall is unwitnessed, and it is not known if the patient sustained head injuries. In this case, had a neurological assessment been done, the staff may have noticed the patient’s deteriorating condition in a timelier fashion and prevented the eventual outcome.

Patient falls in healthcare are among the most common adverse events. Strong processes and continuous staff education on those processes are essential for preventing patient falls.

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About the Authors

Jamie Lamb
Director of Claims Operations, LHA Trust Funds

Jamie Lamb began her career in claims in 1997. Her experience includes handling multi-line claims in the areas of general liability, medical malpractice, automobile liability, commercial and personal property, excess and umbrella policies, and professional liability. Her experience comes as a former Manager and Litigation Specialist for the American National family of companies. She has been highly involved in the education and training of both internal and external customers her entire career. Ms. Lamb attended both Evangel University in Springfield, Missouri, and Loyola University in New Orleans.

Stacie Jenkins, RN, MSN, CPSO
Vice President of Patient Safety and Risk, LHA Trust Funds

Stacie Jenkins is a registered nurse with a master’s degree in nursing informatics. She has more than 20 years of experience in healthcare, working in patient care and quality/performance improvement positions. As the Vice President of Patient Safety & Risk at LHA Trust Funds, she works closely with hospital administrators, risk managers, and nursing staff to improve patient safety and establish best practices. She conducts on-site assessments and gives presentations designed to help clients address their patient safety risk management challenges.