The patient was admitted to the hospital
after she fell at home trying to
go to the bathroom. She broke her left
arm.
Three days after entering the hospital
she fell while trying to close her room
door so she could use the bathroom.
She broke her right arm.
Assessment Started, Not Finished
No Fall-Care Plan
On admission to the hospital the
nurses began imputing data into a fallrisk-
assessment computer program.
The court found that the fall-risk
assessment was not completed and a
fall-care plan was not in place until three
days later.
The care plan was not in effect until
after the patient had already fallen.
On four separate admissions to this
same hospital the patient had been assessed
at high risk for falling and fallrisk
care plans had been implemented
right away upon admission.
The patient had fallen at home. Due
to multiple medical problems the patient
was very weak and short of breath.
For this admission the patient’s
physician ordered strict bed rest, meaning
the patient was not to be out of bed
for any reason, even to use the bathroom