HospitalInspections.org

Based on document review, observation, and interview it was determined that for 1 of 13 patients (Pt #1) reviewed for falls, the Hospital failed to ensure a Registered Nurse supervised and evaluated the nursing care for Pt #1 by not having a bed alarm in place and activated on the bed of a patient at risk for falls, as required.
Findings include:

1. The Hospital's policy titled, Fall Prevention Guidelines" (effective 2/1/2021) was reviewed and required, " ... III. Fall Risk Assessments/Interventions for the Inpatient Setting ... b. Moderate Fall Risk Score (6-13) Interventions include: i. Maintain all basic safety /low risk interventions. ii. Supervise and/or assist with bedside activity and toileting as appropriate ... v. Activate bed alarm, and chair alarm if/when out of bed ... c. High Fall Risk (>13) Interventions include: i. All basic safety/low risk and moderate risk interventions ..."

2. The clinical record of Pt #1 was reviewed on 4/20/2021. Pt #1 was admitted to the Hospital on 4/16/2021 with diagnoses of necrotic abdominal mass with metastasis and anemia (low number of red blood cells). Pt #1's fall risk assessment, dated 4/19/2021, included that Pt #1 was at high fall risk due to having had a fall in the past six months. Pt #1's Johns Hopkins Fall Risk Assessment (fall risk assessment tool), dated 4/19/2021 at 8:37 AM, shows that Pt #1 should have all low and moderate risk interventions in place (moderate interventions include a bed alarm).

3. On 4/19/2021 at approximately 9:45 AM, an observational tour was conducted of the 2 East Unit. Pt #1 was observed to be laying in bed, and the bed alarm (alarm that would notify staff if Pt #1 got up out of bed) was not activated.

4. On 4/19/2021 at approximately 9:50 AM, an interview was conducted with the Manager of 2 East (E #8). E #8 stated that Pt #1's bed alarm should have been on.