HospitalInspections.org

Based on document review and interview, the facility failed to ensure care in a safe setting for 1 of 10 Medical records (MR) reviewed (Patient # 3).

Findings include:

1. Review of established hospital policy titled: "Patient Rights and Responsibilities", indicated on page 3, under right to; 18. "Receive care in a safe setting". Last revised 2/2020.

2. Review of established hospital policy titled: "Patient Observation", indicated on page 2, under procedure, 2. "Level II - 1:1 Observation", a. "The patient is to be under constant visual observation by an assigned staff member, regardless of other unit activities"; b. "Staff member must remain in close proximity to the patient, to include patient toileting activities". Last revised 5/2021.

3. Review of occurrence reports for Patient # 3, indicated the following:
A. Occurrence, dated 4/21/2021, reflected unwitnessed patient fall; occurred at 1:00 pm. Patient found in bathroom by staff. Patient claimed to have hit head.
B. Occurrence, dated 7/18/2021, reflected another patient witnessed patient # 3 falling/slid from wheelchair; occurred at 7:55 pm.

4. Review of Patient # 3's MR, indicated the following:
A. Nurse note on 4/21/2021 at 12:30 pm, reflected patient went to bathroom by herself/himself. Patient was observed on the floor. The patient had an order for 1:1 which was written on 3/5/21.
B. Nurse note on 7/18/2021 at 7:55 pm, reflected patient is on the floor lying on her/his right side. Witnessed by another patient.
The patient had an order for 1:1 which was written on 6/20/21.

5. In interview on 7/26/2021 at approximately 2:09 pm, with administrative staff member A # 8 (Social Worker); indicated that the patient has a history of frequent falls.