HospitalInspections.org

Based on document review and interviews, it was determined that the facility failed to provide care in a safe setting by not engaging the bed alarm for one (1) of one (1) Patient (P # 1).

The findings include:

On May 24, 2023 at 9:30 a.m., Clinical Record reviews for Patient #1 revealed the following:

Hospitalist Admission History and Physical reads in part "March 2, 2023 at 8:48 p.m., [P # 1] admitted with Altered Mental Status (AMS) secondary metabolic encephalopathy."

The nursing assessment revealed "High Risk for Falls" intervention included "side rails, bed alarm, and fall sign."
Staff Member (SM) # 5 explained "bed alarms are standard for high risk patients. It is wired into the call system and must be turned off on bed."

Progress Note on March 5, 2023 at 8:20 a.m. reads in part "At approximately 8:10 a.m., patient was found on the floor lying on left should with a large amount of blood and stool beneath and surrounding [P # 1]. Patient had removed foley with the balloon still inflated. Patient was found to be profusely bleeding from the penis. Patient was assisted on to the sara steady and then transferred to the bed. Vital Signs taken. Patient cleaned up. Stat H & H (Hemoglobin and hematocrit labs) and CT (Cat scan) w/o contrast of left shoulder ordered. Provider notified. Attempted to inform patient's [family] via home phone regarding the patient's fall, however there was no answer and was unable to leave a voicemail. The charge nurse was the first to discover the patient. 5 staff members entered the room to help."

On May 24, 2023 at 11:30 a.m., interview with SM # 7 revealed "the bed alarm is on all beds. Fall risk patients are all set at zone 2 on the bed alarm which is very sensitive. Every employee is educated on the bed including bed alarms in orientation. Hourly rounding is done on all patients; even hours nurses round and odd hours care partners round."

On May 24, 2023 at 11:50 a.m., interview with SM # 5 revealed "bed alarms are standard for all fall risk patients." "The alarm was possibly turned off at 7:54 a.m. during care and not turned back on."

Documentation review included rounding on "March 4, 2023 at 5:49 p.m., 10:54 p.m. and March 5, 2023 at 7:54 a.m."

There was no documentation of re-activation of the bed alarm after care was provided.

No facility fall policy was provided for review.

A review of the CT Left shoulder showed it was negative for fracture. H & H review showed morning results 10.4 and 34.3 and after fall 9.7 and 31.1. No transfusion was ordered.

On May 24, 2023 at 12:00 p.m., interview with SM # 6 revealed "investigation of the incident revealed the bed alarm was not on."

Based on document review and interview, it was determined that the facility staff failed to ensure ongoing monitoring, assessment and documentation for Patients in restraints to include skin integrity, circulation, respiration, intake and output, hygiene and injury for two (2) of three (3) Patients (P), (P # 1 and # 2); and
failed to document an assessment of the Patient's condition by a Physician for three (3) of three (3) Patients (P # 1, # 2 and # 3).

The findings include:

On May 24, 2023 at 9:30 a.m., Clinical Record reviews revealed the following:

P # 1-
Hospitalist Admission History and Physical reads in part "March 2, 2023 at 8:48 p.m., [P # 1] admitted with Altered Mental Status (AMS) secondary metabolic encephalopathy."

Physician Orders read in part "Order date/time 03/06/2023 1:46 a.m., Start date/time 03/06/2023 2:00 a.m., End date/time 03/06/2023 1:59 p.m. Restraint Monitoring Q2 hours revealed restraint type: soft restraints bilateral wrists, Justification for order: pulling lines, tubes, dressing, equipment."

There was no nursing assessment documented between 3:51 a.m. and 8:00 a.m. on 03/06/2023 for restraint monitoring.
There was no documentation of an assessment by the Physician regarding the application of restraints.

When asked to provide documentation, Staff Member (SM) # 5 stated there was no documentation by the Physician regarding restraints.

P # 2-
Physician Orders read in part "Order date/time 05/21/2023 8:17 p.m., Start date/time 05/21/2023 8:00 p.m., End date/time 05/22/2023 11:59 p.m. Restraint Monitoring Q2 hours revealed restraint type: soft restraints bilateral wrists, Justification for order: pulling lines, tubes, dressing, equipment."

There was no nursing assessment documented between 4:00 p.m. and 8:00 p.m. on 05/22/2023 for restraint monitoring.
There was no documentation of an assessment by the Physician regarding the application of restraints.

When asked to provide documentation, Staff Member (SM) # 5 stated there was no documentation by the Physician regarding restraints.

P # 3-
Physician Orders read in part "Order date/time 05/21/2023 6:26 a.m., Start date/time 05/21/2023 5:45 a.m., End date/time 05/22/2023 11:59 p.m. Restraint Monitoring Q2 (every 2) hours revealed restraint type: soft restraints bilateral wrists, Justification for order: pulling lines, tubes, dressing, equipment."

There was no documentation of an assessment by the Physician regarding the application of restraints.

When asked to provide documentation, Staff Member (SM) # 5 stated there was no documentation by the Physician regarding restraints.

On May 24, 2023 a review of the facility policy titled "Restraints" reads in part "A physical or psychological face to face assessment must be done by the MD/NP/PA within a calendar day of the restraint order.
Nursing staff will perform and document the following assessments/interventions at least every 2 hours: visual/safety check, circulation, range of motion, psychological status, offering and assisting with food/fluids and offering and assisting with toileting."

On May 24, 2023, the findings were discussed with SM # 4 and # 5 during the exit interview.