What fish-bone diagram for this scenario?

You are the Health Information Director at a 150-bed skilled nursing facility. You have many hats to wear. You are the HIPAA Privacy Officer, particiand ,pate actively in clinical quality monitoring, risk management and utilization review activities (congratulations!). Part of the clinical quality monitoring is the reviewing of all falls that occurred within the past 24 hours to identify potential concerns and patterns. This is a summary of a recent fall.

At 6:30 on Tuesday evening, Betsy was found in the shower room on the floor. She was able to call for help before attempting to get up. The responding staff member (Lynn) asked her to stay still while she went for help. It took her some time to find enough staff to use the scoop chair to get Betsy off of the floor. Lynn is a new CNA and has only been at the facility for 6 months. She did not remember to use the special code word of "Dr. Dove" to indicate a resident in need in the shower room. The charge nurse and supervisor responded and did a preliminary examination and determined she could be moved. Betsy was scooped off of the floor and placed on a stretcher where she could be examined more thoroughly. The supervisor asked both Lynn and the charge nurse, Bill, to complete a statement and to document it The resident within assistanthavewas Betsy's record.

Lynn wrote a statement that stated Betsy slipped in water getting into the shower today and used the same wording in the medical record progress note. Bill's progress note stated, "I was called to the shower room at 6:45 pm. Betsy was found on the floor near clear liquid. Resident was crying and said she was embarrassed as she had no clothes on. After draping her with a blanket, a preliminary examination was completed. Betsy indicated that she hurt her hip when she fell. The physician was notified and a stat x-ray was ordered of the hip. Family notified and incident report completed." JoAnn, the Supervisor, documented in the record that all extremities had a good range of motion even though Betsy claimed her right hip hurt a little and wanted Tylenol.

At the time you are reviewing the medical record on Wednesday at 8:45, you are unable to locate a copy of the incident report and you do not see a verbal order for the stat x-ray. You see a report for a left hip x-ray completed at 10:00. Betsy's care plan indicates she is an assist of one for showering and needs frequent reminders to wait for staff.

You enter the event into your logs for tracking purposes and you see there has been several falls in the shower room in the evenings over the past weeks. You decide to investigate the events further and review the incident reports. The incident Bill completed states the resident slipped on clear liquid and that the bath bathwaterto had not been drawn yet. For the question, "could this event have been prevented?", the response was, "yes, maintenance needs to fix the leaky faucet". You ask the head of maintenance whether a work order has been submitted. He indicates it has been repeatedly submitted by the staff even though they have been told the part is on back order. You decide to notify the facility's administrator as this will be a potential department of health audit. The administrator is able to determine the maintenance department submitted a purchase order for the broken part a few weeks ago but hadn't followed up with the supplier. A phone call to the supplier indicates they do not have a purchase order but they do have the missing part. The part will be delivered on the truck next week. The administrator stated that would be fine and thanked them for their help.

As someone who is involved in quality improvement activities and risk management, you know this needs to be investigated thoroughly.

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