HospitalInspections.org

A. Based on observation, record review and staff interview, it was determined the hospital failed to identify and correct environmental hazards in the patient care areas, such as long telephone cords, that could cause a patient to trip or fall. This deficient practice was identified in one (1) of eleven (11) patient records reviewed (patient #1). Failure to ensure all patients are cared for in a setting that has eliminated possible trip hazards may result in patient accidents with injuries or negative outcomes.

Findings include:

1. Review of the medical record for patient #1 revealed the patient was a seventy-nine (79) year old female who was admitted to the hospital on 1/31/13, with a diagnosis of COPD and weakness. The patient was admitted to Room 304, Bed #1. In the initial admission assessment, the patient was identified as being a high risk for falls, and fall precautions were initiated. The high risk for falls was listed as problem #2 on the patient's care plan, which was completed on 1/31/13 at 1800 hours. The high risk fall plan included using a fall risk sign, putting a fall risk arm band and a bed alarm on the patient, and a yellow blanket on the bed.

2. On 2/3/13 at 1825 hours, nursing documented, "patient found in floor states she was going to bathroom and tripped over phone cord." There was no documentation of any corrective action taken to address or eliminate the trip hazard from the phone cord.

3. On 3/19/13 at 0845 hours, the survey team toured the 3rd floor. Observation of the bedside table in Room 304, Bed #1, revealed there was a telephone with a cord that was piled up on the table. The cord, when extended out, measured eighteen (18) feet long. There were no safety devices to secure the cord off of the floor and out of patient walkways.

4. On 3/19/13 at 1000 hours, the Community Chief Nursing Officer was interviewed. When questioned about the fall involving patient #1, and the long phone cords, she agreed they had not identified the issue, or taken any action. She asserted that since the problem has been identified, immediate action will be taken to prevent any further patient accidents.

5. On 3/19/13 at 1345 hours, the Chief Nursing Officer and the Director of Risk Management informed the survey team the hospital is currently replacing seventy-five (75) in-use phone cords with seven (7) foot phone cords that will eliminate any possible tripping hazards for patients. The Risk Manager stated all cords will be replaced by 3/22/13.

B. Based on document review, record review and staff interview, it was determined the hospital failed to enforce policies/interventions relative to the application of bed alarms on high risk fall patients. Additionally, the hospital failed to have a sufficient number of bed alarms to use on patients at a high risk for falls. This deficient practice was identified in one (1) of eleven (11) patient records reviewed (patient #1). Failure to follow policies for fall risk interventions relative to bed alarms, including maintaining a sufficient number of alarms to place on high risk fall patients, can result in patients ambulating without assistance, with resulting falls or injuries.

Findings include:

1. Review of the policy for fall prevention, Reference # F-11-08 (approved 10-21-05), revealed, in part, the following for high risk fall interventions:

"In addition to low risk fall interventions high risk fall precautions include but are not limited to:

Relocate patient for better visualization
Do not leave unattended in bathroom
Application of bed alarms"

2. Review of the medical record for patient #1 revealed the patient was a seventy-nine (79) year old female who presented for direct admission to the hospital on 1/31/13 with a diagnosis of COPD and weakness. The patient was admitted to the 3rd floor in Room 304, Bed #1. An initial admission assessment was completed and the patient was identified as being a high risk for falls, and fall precautions were initiated. The high risk for falls was listed as problem #2 on the patient's care plan, which was completed on 1/31/13 at 1800 hours. The high risk fall plan included using a fall risk sign, putting a fall risk arm band and a bed alarm on the patient, and a yellow blanket on the bed.

3. On 2/3/13 at 1825 hours, nursing documented, "patient found in floor states she was going to bathroom and tripped over phone cord. Bed alarm was going to be applied but we don't have any on floor at present time and have none that worked."

4. Registered Nurse #2 (RN2), who cared for the patient after she fell, was interviewed on 3/20/13 at 1445 hours. When questioned about the patient not having a bed alarm on, he stated the patient's call bell was within reach, but admitted the patient did not have an alarm on and should have. He explained they have a very limited number of bed alarms and a lot of the time they will need to go to other units to try and find one to use on their patients. He added there are usually several alarms in the drawer at the nurses station that don't work and can't be used on patients.