Insufficient Follow Up for Injuries Sustained During Hospital Falls

Millwood Hospital was cited by the Centers for Medicare and Medicaid Services (CMS) for failing to ensure that its Registered Nurses (RN) properly assessed and evaluated patients under their care. CMS found that two patients were not properly assessed following their respective falls within the facility. One patient’s nursing documentation stated that her husband informed staff that his wife was worse than when she came in, had fallen out of bed, and demanded a physician to evaluate her. However, there was no documentation indicating that her knees were assessed for redness, swelling, or bruising.

In another case, an elderly patient had sustained a hip fracture after getting up from her chair at the facility.  Video footage showed that she fell to the right side and then backwards onto the floor. Despite hitting her head and complaints of right hip pain, there was no indication that the patient was given a head to toe assessment for her neurological status or hip swelling/bruising. The facility gave her Tylenol for pain, Haldol for agitation, and took an X-ray, but the patient was not immediately transferred to another facility for further medical intervention for her hip fracture. Nursing notes showed that the patient fell at approximately 18:00 on 10/19/11, but the patient was not transferred for “‘further management and evaluation'” until about 00:50 on 10/20/11. As a result of the incidents, the facility had to submit a plan of correction to address its cited deficiencies and deficient patient assessment practices.