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MEDICAL CITY ARLINGTON

3301 MATLOCK ROAD

ARLINGTON, TX 76015

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Complaint # TX00399635 was Substantiated with deficiencies cited.

Based on interview and record review, one of ten patients (Patient #1) did not receive care in a safe settiing in that the bed alarm was not appropriately minitored if it was on at all times.

Findings included:

Patient #1 was diagnosed with Dementia and was assessed as High Risk for Falls. The hospital was unable to provide and monitor that high fall risk precautions were implemented and observed at all times while providing care to the patient. The practice was not consistent with the Medical City Arlington Policy #: PCS 080. Title: Fall Prevention: Effective Date: 06/28/2016 Date Revised: 02/2019. Purpose: To describe a systematic approach to reduce patient falls and/or if the patient does fall, prevent injury from the fall. IV. Procedure: IV. Implementation of High Fall Risk Precautions in addition to above will include: High Fall Risk Precautions will be implemented for all patients identified as high fall risk, will be based on individualized nursing assessment, and will include all the following:
o Keeping bed/chair alarms on at all times unless patient is alert and oriented and refuses. If patient refuses, risks of refusal must be explained to the patient and documented in the medical record....

When the fall incident happened, it was noted that the bed alarm was off, and Patient #1 was getting out of bed by himself without the staff knowing. Patient #1 had a ground level fall resulting to laceration on his head. After the incident, a post fall analysis was done by the hospital's Fall Team with the following additional findings:
o Was patient's room close to the nursing station? NO
o Was patient in a camera room? NO
o Call light was easily accessible, but Patient #1 had dementia and was confused and cannot remember how to call.

The hospital needs to provide an action plan to ensure that interventions for high fall risk patients are implemented at all times thereby preventing occurrence of further falls related to the incident.