HospitalInspections.org

Based on document review, observation and interview, nursing administration failed to provide supervision of 1:1 care on 1 of 10 (Patient 4) medical records reviewed.

Findings Include:

1. Review of policy titled: Fall Prevention Protocol last reviewed/revised 07/2019, indicated that Safe Sitter/1:1 supervision will be within 3 feet/arm's length reach of patient at all times.

2. Review of video of incident which took place on 01/28/20 at 7:53 am, this surveyor observed a table in the milieu with the patient sitting in a wheelchair with a chair alarm on. The patient was located about mid-table on the south side and P52 (1:1 Certified Nursing Aide) was standing in the northwest corner of the table; more than 3 feet/arm's length reach away from patient. The patient stood up from the wheelchair; the chair alarm was still connected and the aide was distracted by sorting papers. When the patient fell, the chair alarm disconnected and the aide came running around the table to assist.

3. Interview on 02/19/20 at approximately 11:00 am with P50 (Director of Nursing) confirmed telephone conversation on 02/03/20 with family that patient had a fractured hip.

4. Interview on 02/19/20 at 1:45 pm with P50 confirmed that P52 was not within 3 feet/arm's length reach of patient at time of fall.