HospitalInspections.org

Based on document review, observations and staff interview it was determined the hospital failed to ensure that all lift chairs have safeguards which prevent vulnerable or impaired/confused patients from accessing and inadvertently activating chair controls. This deficient practice was found in one (1) of one (1) patient records reviewed in which an accident occurred during hospitalization (patient #1). Failure to ensure that all patients are cared for in a setting that prevents them from accessing lift chair controls can result in possible patient accidents with negative outcomes.

Findings include:

1. Review of the medical record for patient #1 revealed the patient presented to the emergency room on 1/7/13 after suffering a fall. The patient was treated in the emergency department and found to have a fracture of the first and second vertebrae. Additional diagnosis included severe mental retardation. A cervical collar was applied and the patient was admitted. The physician ordered the patient to be up in the chair two (2) times a day starting 1/9/13. A nurses note on 1/22/13 at 1131 hours documented notifying the physician of the patient removing sterno-occipital-mandibular immobilizer (somi) brace and other neck brace. On 1/23/13 at 0855 hours nursing documented the patient was found on the floor by bedside and the recliner was up in maximum lift.

2. On 3/4/13 at 1245 hours a tour of 5 south nursing unit was conducted. During this tour a demonstration of how the electric patient lift/reclining chairs works was done. It was observed the chair is able to tilt forward and lift the patient into an almost standing position. In full lift the back of the patient seat is approximately thirty (30) inches from the floor and the front of the seat is twenty-four (24) inches from the floor. At full lift the patient seat is approximately at a forty (40) degree angle and it takes about twenty-two (22) seconds for the chair to go from full recline to full lift position. The controls to raise and lower the chair consists of two (2) buttons located on the left side of the chair nine (9) inches from the chair front and two (2) inches below the armrest on the outside of the chair. These controls are readily accessible by any patient sitting in the chair. There are no safety measures incorporated in the chairs to prevent confused or impaired patients from accidentally triggering the motion controls except to unplug the unit. It was noted that all patient rooms have these electric lift chairs.

3. The manager of 5 south was interviewed on 3/5/13 at 1110 hours. She stated that she and the registered nurse (RN), who cared for patient #1, reviewed everything that happened concerning the above incident. She said that "at no time did we ever think the patient could ever have pushed the lift button on the side of the chair." The manager added that after this incident they notified all nursing personnel that when confused patients or children are in the lift chairs they are to be unplugged.

Based on document review and staff interview it was determined the medical staff failed to enforce bylaws that require that all medical records be completed by the responsible medical staff members thrifty (30) days from the date of discharge, this includes the discharge summary with final diagnosis. This deficient practice was found in one (1) of three (3) discharge records reviewed (Patient #1). When discharge summaries are not completed in the required timeframe can result in a failure to identify issues or medical problems that occurred during hospitalization which could negatively impact the care of patients.

Findings include:

1. Review of the medical staff bylaws/rules and regulations (revised 12/18/12) revealed the following in part: All Practitioners involved with the case shall have thirty (30) days from the date of discharge in which to complete the medical record which includes the final diagnosis and condition on discharge.

2. Review of the medical record for patient #1 revealed the patient was admitted on 1/7/13 and discharged on 1/23/13. At the time of record review on 3/4/13 at 1000 hours there was not a discharge summary available for review.

3. The Administrative Assistant on 3/4/12 at 1300 hours reviewed the electronic record and was unable to find the discharge summary.

4. On 3/5/13 at 0900 hours a copy of a discharge summary was made available for review. The discharge summary was dated as being dictated on 3/4/13 at 1458 hours and typed on the same day at 1512 hours. This was thirty-nine (39) days after discharge of the patient and represents a violation of the medical staff bylaws.

I. Based on document review and staff interview it was determined the hospital failed to ensure that all nursing personnel are fully trained in the safe operation and management of electrical lift/reclining chairs especially when confused or cognitively impaired patients are placed in them. Failure to have all personnel fully trained and competent on the safe management and operation of these units can result in patient accidents with adverse outcomes.

Findings include:

1. On 3/4/13 at 1000 hours a request was made for nursing staff safety orientation/training to all lift equipment including the electric lift chairs including when confused or cognitively patients are placed in them.

2. During an interview with the Education Coordinator on 3/4/13 at 1415 hours she stated that when they moved into the new hospital all personnel were oriented to all of the equipment including the lift chairs which were not in the old hospital. When questioned about safety training on the use of the lift chairs especially relative to confused or disoriented patients she stated they do not have any documented training. Additionally, she was unaware of any policies or procedures pertaining to lift chair safety and accident prevention.

II. Based on document review and staff interview it was determined that nursing failed to provide documented evidence of following safety policies which specifies that when a fall occurs, a patient is not to be moved until assessments are completed that include vital signs, level of consciousness and new neurological findings. This deficient practice was found in one (1) of one (1) records reviewed in which a fall occurred during hospitalization (patient #1). When there is no documented evidence of following the safety process after a fall can result in unidentified patient care issues which could result in future adverse patient outcomes.

Findings include:

1. Review of the Adult high fall risk safety program (revised 2/11) revealed in part the following assessments that need to be followed if a fall occurs on a nursing unit:
A. Do not move patient until you assess for injuries which includes in part:
1. Vital signs
2. Passive range of motion
3. Neurological exam (level consciousness, pupil reaction, grips, etc)
4. Neck exam or new neurological findings.

2. Review of the medical record for patient #1 revealed the patient presented to the emergency room on 1/7/13 after suffering a fall. The patient was treated in the emergency department and found to have fractures of the first and second vertebrae. Additional diagnosis included severe mental retardation. A cervical collar was applied and the patient was admitted.
3. On 1/23/13 at 0855 hours nursing documented the patient was found on the floor by bedside and the recliner up in maximum lift. Patient lifted to bed and bed alarm attached. The record lacked any documentation of the patient's physical appearance, assessment of any system, patients level of consciousness and any new neurological findings. There was no documentation of any safety measures used in moving a patient with a known cervical fracture.
4. Registered Nurse #1 (RN#1) on 3/5/13 at 1420 hours reviewed the above record and agreed there was no documentation concerning patient assessment and findings prior to moving the patient to the bed.