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Based on record review, interview and policy review, the facility failed to assess a lap seat belt device prior to application to determine if it was a restraint for a patient who was at high risk for falls (A0159). This affected seven (Patients #3, #4, #6, #7, #8, #9 and #10) of 11 sampled patients. The census was 344 patients.

Based on record review, staff interview and policy review, the facility failed to assess a lap seat belt device prior to application to determine if it was a restraint for patients that were at high risk for falls. This affected seven (Patients #3, #4, #6, #7, #8, #9 and #10) of 11 sampled patients and had the potential to affect any patient evaluated as a high fall risk and requiring interventions. The facility had a census of 344 patients.

Findings include:

1. Review of the medical record for Patient #3 revealed he was admitted on 08/23/20 with diagnoses including schizoaffective disorder. Review of the nursing flow sheet record revealed a high fall risk with a Morse fall risk score greater than 50 points, indicating the patient was at high risk for falls.

Review of the nursing flow sheet revealed initially bed and chair alarms were in use. On 09/03/20, a self-release lap belt was documented in use. There was no assessment to indicate if the lap belt was a restraint or if Patient #3 was able to release and remove the belt on his own.

2. Review of the medical record for Patient #4 revealed he was admitted on 06/17/20 and had diagnoses including acute respiratory failure with hypoxia.

Review of a nursing flow sheet revealed a self-release lap belt was documented in use on 07/01/20 and 07/02/20. There was no assessment to indicate if the lap belt was a restraint or if Patient #45 was able to release and remove the belt on his own.

3. Review of the medical record for Patient #6 revealed an admission date of 08/10/20 with diagnoses including meningioma.

Review of a nursing flow sheet revealed bed and chair alarms and a yellow arm band were in place. Review of a speech therapy (ST) note dated 08/12/20, an occupational therapy (OT) note dated 09/01/20 and a physical therapy (PT) note dated 09/03/20 revealed Patient #6 had a lap belt with an alarm in place. There was no assessment to indicate if the lap belt was a restraint or if Patient #6 was able to release and remove the belt on her own.

4. Review of the medical record for Patient #7 revealed an admission date of 08/26/20 with diagnoses including high blood pressure, acute encephalopathy, chronic obstructive pulmonary disease and lung cancer.

Review of a PT and OT notes dated 09/02/20 revealed Patient #7 had a self-release lap belt with an alarm while seated in a chair in the patient's room. There was no assessment to indicate if the lap belt was a restraint or if Patient #7 was able to release and remove the belt on his own.

5. Review of the medical record for Patient #8 revealed he was admitted 07/06/20 with diagnoses including left cranioplasty, craniotomy and history of a stroke with a right side deficit.

Review of nursing flow sheet dated 07/08/20 and 07/09/20 revealed a self-release alarming belt was in place while the patient was in a chair. Review of OT notes dated 07/08/20 and 07/10/20 revealed a description of Patient #8 seated in a chair with a self-release belt alarm in place. There was no assessment to indicate if the lap belt was a restraint or if Patient #8 was able to release and remove the belt on his own.

6. Review of the medical record for Patient # 9 revealed an admission date of 06/24/20 with diagnoses inlcuding a fall at home.

Review of the nursing flow sheet dated 06/25/20 and 06/26/20 revealed Patient #9 was identified at high risk for falls per the Morse fall risk score, had poor judgement, poor safety awareness, confusion, impulsiveness and forgetfulness. On 06/27/20, a self-release lap belt was in place. There was no assessment to indicate if the lap belt was a restraint or if Patient #9 was able to release and remove the belt on his own.

7. Review of the medical record for Patient # 10 revealed an admission date of 09/08/20 with diagnoses including chronic atrial fibrillation with right ventricular regurgitation.

Review of documentation in the nursing flow sheets revealed Patient #10 was assessed with impaired cognition and decreased safety awareness, was oriented to person, but a poor historian, followed commands 75% of the time, but required frequent cueing to stay on task. His Morse fall scale risk score was 85, indicating high risk for falls.

Review of therapy notes dated 09/09/20, separate visits by PT, OT and ST revealed descriptions of Patient #10 seated in a chair with a self-releasing lap belt in place. Review of the nursing flow sheets dated 09/08/20 and 09/09/20 revealed an alarming self-release lap belt was in use. There was no assessment to indicate if the lap belt was a restraint or if Patient #10 was able to release and remove the belt on his own.

8. Interview with Staff A on 09/17/20 at 12:19 PM confirmed there was no assessment indicating whether the lap belt was being used as a restraint for Patients #3, #4, #6, #7, #8, #9 and #10.

9. Interview with Staff K on 09/15/20 at 11:28 AM revealed the hospital fall protocol included the use of signs, yellow arm bands and yellow non skid socks. A sitter could be assigned if a patient care technician or other trained staff was available to sit one on one with patient who was at high risk for falls. The facility also used "restraint alternatives" for high risk patients whose assessments revealed they required an additional reminder not to ambulate without assistance. "Restraint alternative" devices included lap belts that buckled and a fabric belt with Velcro loop closure and an alarm that sounded when a patient unfastened the belt. Staff K stated the "restraint alternatives" were used only on a patient who could release the belt on their own, therefore, the devices were not considered a restraint.

10. Interview with Staff G on 09/15/20 at 2:07 PM revealed the Velcro self-release alarm belt was in a trial phase and no specific designated item had been placed in the facility's electronic medical record system to identify the device. Staff G stated staff would ensure a patient could pull off the "restraint alternative" Velcro belt and said an education section in the record had documentation about the education given to the patient about the fall prevention program, though nothing specific was documented about the patient's ability to release the device.

11. Review of a manufacturer video on 09/16/20 at 11:19 A.M. describing the Velcro alarm belt revealed the "Head Start Notification Sensor Belt" had a dual loop design, foam construction for single use and a cord connected to an alarm box. The belt was fashioned with yellow straps on either side when placed across a patient. When the yellow straps were unfastened, the alarm would sound to alert staff. The device was described as "a gentle reminder to stay seated" and if easily removed by the patient, it was not a restraint.

12. Review of the hospital policy titled "Fall Prevention"., policy number 28.00, effective 04/2003 and revised 09/2019, revealed all patients were to be screened using the Morse Fall Scale upon admission to the facility and the unit, following a significant status change, with each change of caregiver (shift) and after a fall. The scores of the fall assessment were to be documented in the electronic medical record and the caregiver is to determine the severity of the risk based on the score and implement appropriate prevention interventions. Review of the intervention measures in the fall prevention policy specific to in-patients revealed fall prevention and safety education is provided to all patients upon admission to the inpatient units.

The fall prevention interventions revealed three tiers of fall prevention measures. The first tier was 4. Standard fall prevention interventions, featuring a list of possibilities depending on the assessment of the individual patient, in conjunction with the Morse Fall Scale, "low risk" value of 0-24. The first tier interventions included such things as orienting the patient to the environment, ensuring the patient can operate the call light, maintaining the call light in reach, instructing the patient to call for assistance, keeping items within patient reach, putting the hospital bed in low position, locking beds and wheelchairs, using non-slip footwear, assessing medications and maintaining adequate lighting.

The second tier featured interventions for "moderate risk" patients with a Morse Fall Scale of 25-50. The additional interventions were to be selected based on an individual assessment of the patient. Interventions included frequent re-orientation to the environment and leaving the bathroom light on at night.

The third tier of the fall scale for scores greater than 50 on the Morse Fall Scale were considered "high risk" and interventions included applying a yellow arm band to the patient, placing a sign indicating fall risk on their door, featuring a yellow banner within the electronic medical record, instructing the patient to call for assistance, implementing an individualized toileting schedule, use of transfer belts and assistance equipment, use of a chair of bed alarm, locating the patient to a room close to the nursing station, order therapy services as appropriate, use an activity cart, employ a restraint alternative, i.e. self-releasing lap belt, and restraints as needed.