Surveyor Consensus & Allocation Dispute
Team leader to resolveLead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorFully met
Pn Zaiton AbdullahRecorded finding during tracer inspectionAwaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.
5.3.1
Safety and performance improvement activitiesPatient Fall Prevention and Management
A multidisciplinary fall prevention programme includes universal fall risk assessment, targeted interventions and post-fall clinical evaluations.
Compliance Criteria
- 1Standardized fall risk assessment (e.g. Morse / Hendrich II) on admission and daily
- 2Visual fall alert signage, yellow wristbands and low-height bed placement for high-risk patients
- 3Post-fall clinical assessment, medical review and incident notification within 24 hours
- 4Quarterly monitoring of inpatient falls rate per 1,000 patient bed days
Hospital Self-Rating
Rated by Matron Norliah binti Hashim on 19 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Inpatient fall prevention protocols are in place with Morse Fall Scale assessments. Post-fall evaluations and incident reports are submitted within 24 hours."
thin
Evidence documents establish procedural intent but lack documented verification records for the current audit period.
Unverified criteria:
- Post-fall clinical assessment, medical review and incident notification within 24 hours
- Quarterly monitoring of inpatient falls rate per 1,000 patient bed days
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (1)
PolicyStaleScore: 62/100
Inpatient Fall Risk Assessment & Universal Prevention Protocol (2023)
Fall protocol references obsolete Hendrich scoring form rather than current Morse Fall tool.
22 pages · ENValid: 2023-03-01 to 2024-11-30
Linked Performance Indicators (1)
PI-06-014Nursing & Patient Safety
Inpatient Fall Rate with Injury per 1,000 Patient Bed Days
18 readings recorded (Target: <= 2per 1,000 bed days)
NH
Person-in-ChargeDirector of Nursing
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Pn. Zaiton Abdullah (Nursing & Quality Surveyor)