When Enhanced Care Nursing Assessment Is Overlooked: Preventable Fall Risk and Policy Breach

Assessing the cost of missed enhanced care opportunities in confused patients

When a confused elderly patient is admitted to hospital with a high falls risk, the expectation is clear: policies should trigger timely assessments that safeguard the individual’s wellbeing. Yet in this case, despite comprehensive Trust policies and evident warning signs, an enhanced care nursing assessment was never actioned. The patient suffered a fractured arm following an unwitnessed fall—an outcome a nursing expert concluded was entirely avoidable.

Missed nursing interventions: where policy met inaction

Although this patient was appropriately identified as high risk for falls and had a care plan in place, the failure to implement enhanced care planning is where the breach occurred.

The Trust’s own documentation highlighted:

• A requirement to complete enhanced care assessments for patients who appear to lack capacity, especially after a fall.

• Cohorting or eyesight-level care as standard when confusion or mobility issues are present.

• Risk assessment within six hours of ward admission.

Despite these expectations, nursing records failed to reflect any completed enhanced care assessment, even after clear incidents—including an earlier fall and nursing concerns about bed mobility.

“Cohorting care would have likely prevented the fall that led to the fracture. There were missed opportunities to act.”— Independent Nurse Expert, Apex Experts

Why enhanced care nursing assessments matter

An enhanced care nursing assessment is a critical tool used by hospitals to determine when a patient requires one-to-one or increased observation. It is particularly vital when a patient:

1. Presents with acute confusion or delirium.

2. Is at risk of self-harm or accidental injury.

3. Has fallen or is likely to fall due to impaired cognition or mobility.

In this case, the patient’s cognitive status was noted early in her admission. Nursing staff expressed concern about her ability to mobilise safely, but this did not trigger escalation to enhanced care pathways—despite Trust guidelines clearly supporting such action.

Learning for litigation and clinical governance

This incident is a textbook example of how:

• High-quality policies are not enough without clinical follow-through.

• Nursing documentation must reflect proactive risk management.

• Timely enhanced care nursing assessment processes should be embedded in admission protocols.

Litigation teams will note that despite the medical staff’s rationale for not undertaking a formal capacity assessment, nursing staff still had a duty to protect the patient using the tools available to them—particularly after the first fall.