HospitalInspections.org

Based on policy review, medical record reviews, grievance review, observations, and staff interview the hospital staff failed to ensure bed alarms were activated on 3 of 6 patients. (Patient #3, Patient #25, and Patient #28)

Findings include:

Review of the hospital policy titled "Fall Risk Assessment, Prevention and Management" revised 08/25/2020 revealed "Purpose...2. Implement interventions based on the patient's identified risk...Policy: [Named Facility] will assure the safety of all patients by providing a safe and secure environment. This policy provides for assessing...the prevention and management of any fall event...2. Patients at High Risk: implement high risk interventions, in addition to low risk interventions. c. Utilize fall prevention interventions from the Fall Prevention Bundle specific to the specialty needs of the patient...B: Inpatient Fall Bundle, Interventions...Bed alarm and chair alarm for score of greater than or equal to 10..."

1. Closed medical record review revealed Patient #3, admitted on 12/31/20 at 1317 for increased confusion, and difficulty ambulating, with a medical history of Parkinson's Disease and Normal Pressure Hydrocephalus. Review of the Physician Orders documented on 01/01/2021 at 0223 by Medical Doctor #1 revealed an order placed for Patient #3 of "Fall Precautions." Review of the Safety Flowsheet dated 01/01/2021 at 0530 by Registered Nurse (RN) #3 revealed a Fall Risk Score of 17 (high fall risk). Review of the Safety Flowsheet dated 01/02/2021 at 0900 by RN #1 revealed a Fall Risk Score recorded of 17. Review of the Nursing Flowsheet dated 01/03/2021 at 0400 revealed that the High-Risk Fall Bundle was implemented by RN #2. Review of the Nursing Progress Note dated 01/03/2021 at 0630 by Registered Nurse (RN) #1, revealed "Called to room by charge nurse. Patient was found on the ground near bed on the floor. She states she was trying to find someone to help get her dressed. Patient has intermittent confusion but is usually easily redirected...No injury was noted. Notified Tele Sitter (sic) was ordered and low bed. Bed alarm was reactivated." Review revealed that the bed alarm was not utilized per physician order to prevent a fall.

Review on 03/10/21 of the grievance report dated 01/05/2021 at 1231 by Patient Experience Manager #1 revealed "Bed alarm did not activate at time of fall. Individualized re-education on use of bed alarms..." Review of the grievance report dated 01/07/2021 at 1222 by Assistant Director, RN #4 revealed "Bed Alarm was off at time of fall. All staff responsible for ensuring bed alarms are on when entering room."

Request to interview RN #1 revealed that she was unavailable.

Telephone interview on 03/10/2021 at 2034 with RN #2 revealed that when she entered Patient #3's room 01/03/2021 at 0630 two other nursing technicians were already with the patient. Interview revealed that the "patient was found sitting on the floor in urine, and the bed alarm was not on." Interview revealed this was an unwitnessed fall. Interview with RN #2 revealed that "sometimes when staff go into a room to clean a patient, the bed alarm may be forgotten." Interview revealed she called her Director at home, called Patient #3's doctor and husband, and notified the house supervisor. Interview revealed that she did not find any injuries on post fall assessment, and that she reported to RN #1 at the bedside at the end of shift.

2. Open medical record review revealed Patient #25 was admitted on 03/09/2021 at 0845 for elective lower back surgery and presented to the outpatient surgery department. The Safety Flowsheet revealed a Fall Risk Assessment of 17 documented by RN #6 on 03/11/2021 at 0745. Review revealed that Patient #25 was High Fall Risk.

Observation on the orthopedic floor on 03/11/2021 at 1000 revealed that Patient #25 was lying in bed, and had a bed alarm. Observation revealed Patient #25's bed alarm was not activated.

Interview on 03/11/2021 at 1015 with the Nurse Tech (NT) #1 revealed "Not sure why the bed alarm was off. He is a fall`s risk, and the bed alarm needs to be activated."

Interview with the Nursing Director of the orthopedics floor on 03/10/2021 at 1015 during observation revealed bed alarm should be activated for Patient #25.

3. Open medical record review revealed Patient #28 was admitted on 03/08/2021 at 1809 for bilateral leg weakness. Review of a physician`s order dated 03/08/2021 at 2345 revealed "Fall Precautions." Review of the Safety Flowsheet dated 03/11/2021 at 0730 by RN #5 revealed a High-Risk Assessment was performed and the Fall Bundle Interventions were implemented.

Observation on the orthopedic floor on 03/11/2021 at 1010 revealed that Patient #28 was lying in the bed and had a bed alarm. Observation revealed Patient #28's bed alarm was not activated.

Interview on 03/11/2021 at 1012 with NT #2 revealed "I just gave the patient a bath at 0900, and left the bed alarm activated, I don't know why the alarm is not on, it should be."

Interview with the Nursing Director of the orthopedics floor on 03/10/2021 at 1012 during observation revealed bed alarm should be activated for Patient #28.

Based on policy and procedure review, observations during tours, and interviews with staff, the hospital's dietary staff failed to carry out their respective duties in a competent manner to ensure temperatures were obtained in a safe and sanitary manner in 1 of 1 temperature checks.

The findings include:

Review of policy titled "THERMOMETERS" with date of 04/2006, revealed "...USING THERMOMETERS: Clean and sanitize thermometers before checking foods. Place into center or thickest part of food...."

Review on 03/11/2021 of the box of the sanitizer wipes labeled "Taylor Thermometer Probe Wipes" revealed the box was labeled with "100 single use packs. Directions: Wipe surface vigorously to clean and sanitize. Discard used wipe and packet in trash...."

Observation during tour of the dietary department on 03/11/2021 at 1030 revealed Cook #1 placing thermometer probe into the foods on the line. Observation revealed Cook #1 placed the thermometer into the turnip greens and then wiped the thermometer probe with a newly open sanitizer wipe. Observation revealed Cook #1 then placed the same thermometer probe into the mashed sweet potatoes and then wiped the probe with the same sanitizer wipe. Observation revealed Cook #1 placed the same thermometer probe into the mashed potatoes and then cleaned the probe with the same sanitizer wipe. Observation revealed the Cook #1 used the same sanitizer wipe to clean the thermometer after checking temperatures in three different vegetables.

Interview on 03/11/2021 at 1040 with Cook #1 revealed the sanitizer wipes are changed after 2 or 3 temperature checks. Interview revealed Cook #1 states the sanitizer wipe was used on one side then changed to the other side for the next vegetable.

Interview on 03/11/2021 at 1045 with Senior Chef #2 revealed the sanitizer wipe should be changed with each temperature check of the food item. Interview revealed the cook did not follow what we teach. Interview revealed a new sanitizer wipe should be used for one food item.

NC00174629, NC00174580, NC00173880, NC00172743, NC00172567