HospitalInspections.org

Based on, policy and medical record reviews, interviews, tours, employee records and quality assessment training data, the facility failed to assure care in a safe setting by not following up on safety measures for a patient with a high risk of falls, causing patient injury in one (1) of ten (10) medical records reviewed.

Findings include:

Reviewed policy titled "Prevention of Falls" and dated 1/19/2015. All facility patients are to be considered at risk for falls and are, on admission patients are assessed and put into one of two categories 1=High fall risk or 2=High fall risk with injury. For Category 2 all patients will have bed alarms on when they are in bed.

Review of the nursing assessment of patient medical record #2 revealed the condition on 1/28/15 at 9:00 p.m. to 11:59 p.m. the following was charted as patient was alert, oriented to person and place, weak of grip, and anxious. Plan Of Care: Safety -visual acuity problems, unsteady gait, decreased muscle coordination. Fall risk comment; bed at the lowest level position and locked, call light within reach, frequent rounds. Documentation did not indicate if the bed alarm was working or was turned on. Fall Precautions for the High Risk patient for falls included: non-slip footwear when out of bed, assist with: mobility ADL's, toileting program, secured poles and tubes. Fall precautions education with patient/family/caregiver, and consultation with physical therapy (PT).

Tour of two rooms on the 2nd floor on 6/1/15 at 11:30 a.m. was observed; .Observation on second floor (medical) with QA RN employee, Medical Unit Manager, and lead of engineering department. Entered vacant room 215, for finding the location of the serial number from Hill ROM bed and check the bed alarm for functioning. The Engineer confirmed that the new beds with alarms were checked by facility for electrical safety only. He/she lay down in the bed and The medical floor director demonstrated the functioning of the bed alarm with audible loud alarm and green glow under the bed to assure the bed alarm worked. We preceded to the location of bed serial number P309A09526 in room 236 (the bed, from which patient medical record #2 had exited and subsequently fallen. The bed appeared to be working and the alarm was on because this patient was at a high risk for falls. We could not actually test this bed because the patient was totally bed bound and incoherent. He/she might have been frightened if the alarm were made to sound.

Interview #2 on 6/1/15 at 1:55 p.m. with RN #6 on the 4th floor confirmed that all patients in the hospital were at risk for falls. The facility has two levels as per the Prevention of Falls Policy". Both of the patients at high level of risk for falls.

On 6/2/15 at 2:00 p.m. a interview #8 was conducted, the RN reported when he/she came to the room the bed alarm was on not on and before the patient had fallen. The RN explained he/she went to get a portable one but was unable to locate one at the time. The RN indicated he/she may have requested the clerk to call in a work order for the bed. The patient was still in the bed. The RN stated if a piece of safety equipment was not working that he/she would place a tag on the equipment and it was not used. He/she was not able to tag the bed for out of service because they were no more available beds to place the patient. The RN reported he/she did not notify the supervisor and had not documented that information. The RN indicated there was not a clear policy/guideline on what to do if the portable replacement alarms was not working and they were unable to be replaced on what should be done.
Interview #5 on 6/1/15 at 3:30 p.m. was conducted the Chief Nursing Officer about the problems found with the 87 new beds regarding the bed alarms. These checked before being put into service in the patient care areas. The beds are each coded with a sticker with a unique serial number. After the fall and injury of patient (medical record #2) all 87 new beds were examined regarding the 'out of bed' alarms. There were three (3) (bed unique identifiers: P309A09526, P289A08072, and P289A08075 had defective out of bed alarms. The manufacturer of the beds replaced the alarms on 1/30/15.

The repair order for the bed was requested from the engineer lead of when the clerk called maintenance for request of the bed to be fixed, the engineer acknowledged he/she was unable to find the request order submitted by the RN or clerk for the patient's malfunction bed alarm before or after the patient fell. The engineer lead revealed the next day the company that serviced the bed came to fix by switching out parts of the patient's bed. The facility found 2 additions beds that were also not working appropriately. The new beds were new and placed in service in November 2014 and at that time was working appropriately. The documentation was revived had indicated the company had come to the facility and found the above to be accurate.

Training held for many employees was done on 11/13/14 for fall prevention. Regarding high risk of fall with injury: use of call lights, bed alarms (inclusive of yellow flashing light indicating caution and green lights meaning green light indicates safety and always have brakes on with bed in lowest position, 3 side rails up and always to have the bed alarm on (alarm signaled that patient is potentially out of bed when it audibly goes off). Employee # 2 (registered nurse [RN] on duty and caring for patient medical record #2 at time of fall and injury) received training during this date.

Review of employee files showed that only one (1) of six (6) employees had not had updates in 2015 regarding fall prevention. That person, while a registered nurse (employee #5) did not participate in direct patient care. One such class for review of fall prevention was held on 1/25/15 and employee #2 the same RN who took care of patient #2 received this training. Employee training for prevention of falls did not include how to proceed if and when the out of bed alarm did not work.

Based on, policy and medical record reviews, interviews, employee records and quality assessment training data, the facility failed to assure care in a safe setting by not updating the care plan safety measures for a patient with a high risk of falls, causing patient injury in one (1) of ten (10) medical records reviewed.

Findings include:
Review of medical record #2 revealed the patient came to the facility because of chest pain on 1/27/15. The patient's daughter/son was the main family caregiver and assisted with interpretation to the 89 -year-old Lebanese- speaking. The patient was diagnosed with carcinoma of kidney - stage IV, CAD (Coronary Artery Disease), status post cardiac stint, status post right nephrectomy, hypertension, dyslipidemia, hypothyroidism, fib, previous hip surgery, CHF (congestive a heart failure), Arthritis, Cataracts removed, Hearing deficit. According to the physician's history and physical indicated he/she was unable to obtain review of systems due to patient's baseline mental status. The patient was alert and was unable to understand due to language barrier. The patient had a left hip fracture prior to admission and the patient while at facility sustained a right hip fracture and had surgery on that hip.
Further review of the patient record #2 revealed on 1/28/15 evening shift the patient was alert, oriented to person and place, weak grip, anxious. The patient's Plan Of Care indicated the patient had -visual acuity problems, unsteady gait and decreased muscle coordination. Under the fall risk comment revealed the patient's bed at the lowest level position and locked, call light within reach, frequent rounds, The documentation did not indicate if the bed alarm was working or was on. Fall Precautions for the High Risk patient plan of care was not updated indicating a non functioning bed alarms.
Further record review indicated the weak unsteady non-speaking English patient attempted to get out of the bed. The bed alarm did not sound alerting the staff the patient's may have ben been attempting to get out of the bed. The staff did not respond to the patient until after the nurse heard a loud noise in the patient' s room and found patient on the floor.
Reviewed policy titled "Prevention of Falls" and dated 1/19/2015. All facility patients are to be considered at risk for falls and are, on admission patients are assessed and put into one of two categories 1=High fall risk or 2=High fall risk with injury. For Category 2 all patients will have bed alarms on when they are in bed. Fall Preventions policy indicted; Call lights would be checked for working status. However not specific to the bed alarm and if bed alarm malfunctioned. Review of the above policy lacked explanation what needed to be done when the bed alarms were not working so the staff would have a clear understanding.

Review of the facility policy entitled " Assessment/Reassessment" indicated the RN is responsible for the overall care of the patient, completes the initial (admission) assessment and individualized plan of care to be done by RN within 24 hours of admission including but not limited to current medications, special equipment needed, ADL. Procedure for patient injury involvement: provide immediate assistance at the scene, contact Nursing Supervisor, injury requiring immediate medical attention is to be referred to the ER, complete occurrence report, referral to Supervisor and Department Director who notifies risk Management/On-call Administrator immediately, notify attending physician.
Interview #8 with the Registered Nurse (RN) via telephone on 6/2/15 at 1:45 p.m. reveals he/she was the primary nurse for this patient the night of the fall. He/She describes the event as he/she heard a noise like something falling coming from the room, he/she found the the patient beside the bed on the floor, called for assistance to get patient back into bed, he/she notified the MD to obtain X-ray due to hip pain, notified nursing supervisor. He/She states his/her normal routine is to do the initial assessment for the shift including checking the bed alarm looking for the green light (he/she does not remember if the light was on at initial assessment). The RN states when he/she did check the alarm it would not come on, he/she looked for a "tab" (portable) alarm, he/she could not find one, there was not another bed available to change patient into. Patient was a high fall risk needing to have the bed alarm. He/she does not know if the bed alarm was working at shift change and no-one had communicated this to her. He/she states He/she checked on this patient a lot since the alarm was not working. This patient room was about 20 feet from the nurse station therefore He/she was not moved for closer observation. Moving the patient would be normal when an alarm is not working. RN states He/she had educated the family and patient not to get out of bed without assistance, to use the nurse call button, the son/daughter was present until about 8:30 p.m. that evening and interpreted this to the patient. The call button was not activated at the time of the fall. The patient usually called out for the nurse. He/she states the patient has limited vocabulary. RN states he/she "thinks" he/she told the secretary to put in a work order for the alarm not working.
On 6/2/15 at 2:00 p.m. a further interview #8 was conducted with another surveyor, the RN reported when he/she came to the room, the bed alarm was on not on before the patient had fallen. The RN indicated he/she may have requested the clerk to call in a work order for the bed. The RN reported he/she did not notify the supervisor and had not documented that information. The RN indicated there was not a clear policy/guideline on what to do if the portable replacement alarms was not working or couldn't be replaced.
Interview #9 with the risk manager on 6/2/15 at 1:00 p.m. in the conference room was conducted, the manager reported the family was in the room for a good period of time, the overnight the monitoring is not done as frequent so the patient could get sleep. The family was there before the patient had fallen, and had not requested a sitter was positioned near the nursing station. The patient had a cane at home but did not have an assistive devices.

The repair order for the bed was requested from the engineer manager of when the clerk called maintenance for request of the bed to be fixed, the engineer acknowledged he/she was unable to find the request order submitted by the RN or clerk for the patient's malfunction bed alarm before or after the patient fell. The beginner revealed the next day the company that serviced the bed came to fix by switching out parts of the patient's bed. The facility found 2 additions beds that were also not working appropriately. The new beds were new and placed in service in November 2014 and at that time was working appropriately. The documentation was revived had indicated the company had come to the facility and found the above to be accurate.

Review of the facility's incident log indicated the patient had fallen on 1/28/15 and sustained a right hip fracture.
Review of the facility policy entitled, Occurrence Reporting Process) revealed that an occurrence is any happening out of the ordinary, which results to a potential for injury, actual injury or damage to a patient, visitor, employee, hospital property or public reputation. All incidents would be reported and investigated.
During review of the facility's data with the Chief Nursing Officer (CNO), the CNO explained the facility completed a root cause analysis and it was found that three (3) bed alarms were not working and were replaced. The facility completed maintenance prior to the beds being placed in service and they were working. The bed alarm in question in the patient's room was not working at the time of the incident.