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Based on document review, policy review and staff interview it was determined the hospital failed to ensure one (1) out of ten (10) patients were kept free from harm (see A 144).

Based on record review, policy review, staff interview and observation it was determined the hospital failed to ensure patient #1 was provided care in a safe setting. This failure led to the patient receiving a C-3 (cervical three) fracture of the spinal cord.

Findings include:

1. A review of the medical record for patient #1 revealed a seventy (70) year old male that was admitted to the hospital on 5/9/21 with a right hip fracture he sustained from a fall at home. The patient was receiving hospice services at home. He was admitted to the Surgical/Oncology floor and had surgery on 5/11/21 to repair the hip fracture. He scored as a high-risk fall patient and bed alarms were documented being placed on the patient's bed from 5/10/21 through 5/12/21. On 5/13/21 there was no documentation of the bed alarm being used on the patient's bed. On 5/13/21 at 1:30 p.m. the patient was found laying in the floor in his room. The nurse notified the physician, the patient's medical power of attorney (MPOA), Nursing Supervisor and completed an event report. The physician ordered a Computed Tomography scan (CT scan) of the head and X-ray of right upper and lower extremities. The X-ray revealed the patient had obtained a C-3 fracture of the spinal cord. Vital signs were taken every four (4) hours, but neurological checks were not begun every four (4) hours until 5/14/21 at 12:17 p.m. The patient was placed in a soft collar for stability of the injury. The patient was ultimately discharged under hospice care.

2. A review of the hospital policy entitled "Falls Prevention," reviewed 9/27/17, states, "Focusing on the areas of risk identified by the MFS (Morse Fall Assessment Scale) will help to recognize specific interventions to prevent patient falls. Examples may include but are not limited to the following: ...application of bed alarms ..." The policy further states, "In the event a patient has fallen, the following procedure is to be followed. Patient assessment will be performed based upon factors that contributed to the fall and the nature of the injuries identified. Even if the pt. (patient) shows no signs of distress or has sustained only minor injuries, monitor his or her vital signs and assess neurological status every 4 hours for 24 hours ...."

3. An interview was conducted with Certified Nursing Assistant (CNA) #1 on 6/21/21 at approximately 3:05 p.m. During the interview she stated, "I found patient #1 laying in the floor when I was making my hourly rounds. The bed alarm wasn't going off. I just found him laying in the floor. I called for the RN (Registered Nurse) to come and help me. I have no idea how he managed to get out of that bed. He had been asleep all day. He had been very drowsy and wasn't really talking to me that day. I know the bed alarm was working because I checked it. I have no idea why the alarm wasn't going off." She stated sometimes the bed alarms work just fine and sometimes they don't.

4. An interview was conducted with the Director of Performance Improvement and Quality on 6/22/21 at approximately 9:50 a.m. She concurred that RN #1 did not follow hospital policy and perform neuro checks on the patient every four (4) hours for twenty-four (24) hours after the fall. She concurred there was no documentation to prove the patient's bed alarm was on at the time of the fall.

5. An interview was conducted with the Nurse Manager of the Surgical/Oncology Unit on 6/22/21 at approximately 11:45 a.m. She stated, "The day patient #1 fell out of bed the bed alarm was not going off. I am sure the nurse had it on, but it is not documented. Sometimes the bed alarms work and sometimes they don't. There is no rhyme or reason to it."

6. A tour was conducted of the Surgical/Oncology Unit along with the Nurse Manager on 6/22/21 at approximately 12:15 p.m. The bed alarm pad was placed on bed two (2) in room 204. Once the alarm was activated, there was approximately a five (5) second delay from the time the Nurse Manager got off the bed alarm pad until the alarm went off. The Nurse Manager stated, "The alarms are inconsistent."

7. An interview was conducted with the Director of Facilities on 6/22/21 at approximately 2:00 p.m. He stated, "The call system on the second floor is the oldest system we have. The systems on the third and fourth floor are newer and the bed alarms tie into the call light system. So, if the bed alarm goes off the call light goes off as well, so you are able to hear the call light at the nurse's desk. On the second floor it is not like that. You only can hear the bed alarm go off not both alarms. We had an adapter to use on that floor, but we found out that the system didn't work always. Sometimes the bed alarm may go off, but it wouldn't allow the call light to work. There were a few days the call light system wasn't working appropriately but I had the part overnighted and had it fixed the next day. No one told me anything about not being able to hear the bed alarms."

8. A review of the facility document entitled "Work Order" dated 6/7/21 states, "Nurse call system is not working properly. Lights come on outside of room and beep sound is heard at the desk, but we cannot hear patients on the call system phone at the desk and patients cannot hear us when we answer either."

9. A tour of the second floor Surgical/Oncology Unit was conducted on 6/23/21 at approximately 8:50 a.m. The bed alarms were tested by this surveyor and the Nurse Manager of the unit. In room 202, the furthest room away from the nursing desk, the door was shut, and the bed alarm was turned on. This surveyor could not hear the alarm with the door shut standing approximately five feet from the door.

10. RN #2 and the Nurse Manager concurred at approximately 8:53 a.m. they could not hear the alarm going off with the door shut standing approximately five feet from the door of the room.

11. In room 227 the bed alarm was turned on with the door shut. This surveyor was standing at the nurse's station with the Nurse Manager at approximately 9:12 a.m. and she concurred she could not hear the bed alarm with the door shut.

12. In room 222, the room closest to the nurse's station, the bed alarm was set off at 9:15 a.m. and this surveyor could not hear the alarm while standing at the nurse's station.

13. The Nurse Manager concurred on 6/23/21 at 9:15 a.m. she could not hear the bed alarm going off in room 222 from the nurse's station.

14. An interview was conducted with the Nurse Manager on 6/23/21 at approximately 9:30 a.m. She stated, "Nursing staff has not told me they were having difficulty hearing the bed alarms.
Findings include:

15. An interview was conducted with RN #2 on 6/23/21 at approximately 9:35 a.m. She stated, "Sometimes you can hear the bed alarms and sometimes you can't, it just depends." I couldn't hear the alarm standing by the room (room 202).

16. An interview was conducted with RN #3 on 6/23/21 at approximately 9:40 a.m. She stated, "If the door is shut you cannot hear the alarms."

17. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 6/23/21 at approximately 9:45 a.m. He stated, "If doors are shut you can't hear the alarms. You have difficulty if there is a lot of traffic on the floor. There is a lot of noise and it makes it difficult to hear the alarms."

18. A review of the hospital reporting system revealed a total of eleven (11) falls have occurred on the Surgical/Oncology floor since 1/1/21.

19. An interview was conducted with the Director of Performance Improvement and Quality on 6/23/21 at approximately 1:55 p.m. She concurred that nursing not being able to hear the bed alarms on the Surgical/Oncology Unit could be contributing to the high number of falls on that unit.

Based on record review, policy review, observations and staff interview it was determined the hospital failed to ensure nursing staff followed policy and procedure in one (1) of ten (10) records reviewed (see tag A 398).

Based on medical record review, policy review, observation and staff interview it was determined the hospital failed to ensure nursing staff followed hospital policy and procedure. This failure led to patient #1 falling in their room and receiving a C-3 (cervical three) fracture of the spinal cord. The patient ultimately returned home to the care of hospice.

Findings include:

1. A review of the medical record for patient #1 revealed a seventy (70) year old male that was admitted to the hospital on 5/9/21 with a right hip fracture he sustained from a fall at home. The patient was receiving hospice services at home. He was admitted to the Surgical/Oncology floor and had surgery on 5/11/21 to repair the hip fracture. He scored as a high-risk fall patient and bed alarms were documented being placed on the patient's bed from 5/10/21 through 5/12/21. On 5/13/21 there was no documentation of the bed alarm being used on the patient's bed. On 5/13/21 at 1:30 p.m. the patient was found laying in the floor in his room. The nurse notified the physician, the patient's medical power of attorney (MPOA), Nursing Supervisor and completed an event report. The physician ordered a Computed Tomography scan (CT scan) of the head and X-ray of right upper and lower extremities. The X-ray revealed the patient had obtained a C-3 fracture of the spinal cord. Vital signs were taken every four (4) hours, but neurological checks were not begun every four (4) hours until 5/14/21 at 12:17 p.m. The patient was placed in a soft collar for stability of the injury. The patient was ultimately discharged under hospice care.

2. A review of the hospital policy entitled "Falls Prevention," reviewed 9/27/17, states, "Focusing on the areas of risk identified by the MFS (Morse Fall Assessment Scale) will help to recognize specific interventions to prevent patient falls. Examples may include but are not limited to the following: ...application of bed alarms ..." The policy further states, "In the event a patient has fallen, the following procedure is to be followed. Patient assessment will be performed based upon factors that contributed to the fall and the nature of the injuries identified. Even if the pt. (patient) shows no signs of distress or has sustained only minor injuries, monitor his or her vital signs and assess neurological status every 4 hours for 24 hours ...."

3. An interview was conducted with Certified Nursing Assistant (CNA) #1 on 6/21/21 at approximately 3:05 p.m. During the interview she stated, "I found patient #1 laying in the floor when I was making my hourly rounds. The bed alarm wasn't going off. I just found him laying in the floor. I called for the RN (Registered Nurse) to come and help me. I have no idea how he managed to get out of that bed. He had been asleep all day. He had been very drowsy and wasn't really talking to me that day. I know the bed alarm was working because I checked it. I have no idea why the alarm wasn't going off." She stated sometimes the bed alarms work just fine and sometimes they don't.

4. An interview was conducted with the Director of Performance Improvement and Quality on 6/22/21 at approximately 9:50 a.m. She concurred that RN #1 did not follow hospital policy and perform neuro checks on the patient every four (4) hours for twenty-four (24) hours after the fall. She concurred there was no documentation to prove the patient's bed alarm was on at the time of the fall.

5. An interview was conducted with the Nurse Manager of the Surgical/Oncology Unit on 6/22/21 at approximately 11:45 a.m. She stated, "The day patient #1 fell out of bed the bed alarm was not going off. I am sure the nurse had it on, but it is not documented. Sometimes the bed alarms work and sometimes they don't. There is no rhyme or reason to it."

6. A tour was conducted of the Surgical/Oncology Unit along with the Nurse Manager on 6/22/21 at approximately 12:15 p.m. The bed alarm pad was placed on bed two (2) in room 204. Once the alarm was activated, there was approximately a five (5) second delay from the time the Nurse Manager got off the bed alarm pad until the alarm went off. The Nurse Manager stated, "The alarms are inconsistent."

7. An interview was conducted with the Director of Facilities on 6/22/21 at approximately 2:00 p.m. He stated, "The call system on the second floor is the oldest system we have. The systems on the third and fourth floor are newer and the bed alarms tie into the call light system. So, if the bed alarm goes off the call light goes off as well, so you are able to hear the call light at the nurse's desk. On the second floor it is not like that. You only can hear the bed alarm go off not both alarms. We had an adapter to use on that floor, but we found out that the system didn't work always. Sometimes the bed alarm may go off, but it wouldn't allow the call light to work. There were a few days the call light system wasn't working appropriately but I had the part overnighted and had it fixed the next day. No one told me anything about not being able to hear the bed alarms."

8. A review of the facility document entitled "Work Order" dated 6/7/21 states, "Nurse call system is not working properly. Lights come on outside of room and beep sound is heard at the desk, but we cannot hear patients on the call system phone at the desk and patients cannot hear us when we answer either."

9. A tour of the second floor Surgical/Oncology Unit was conducted on 6/23/21 at approximately 8:50 a.m. The bed alarms were tested by this surveyor and the Nurse Manager of the unit. In room 202, the furthest room away from the nursing desk, the door was shut, and the bed alarm was turned on. This surveyor could not hear the alarm with the door shut standing approximately five feet from the door.

10. RN #2 and the Nurse Manager concurred at approximately 8:53 a.m. they could not hear the alarm going off with the door shut standing approximately five feet from the door of the room.

11. In room 227 the bed alarm was turned on with the door shut. This surveyor was standing at the nurse's station with the Nurse Manager at approximately 9:12 a.m. and she concurred she could not hear the bed alarm with the door shut.

12. In room 222, the room closest to the nurse's station, the bed alarm was set off at 9:15 a.m. and this surveyor could not hear the alarm while standing at the nurse's station.

13. The Nurse Manager concurred on 6/23/21 at 9:15 a.m. she could not hear the bed alarm going off in room 222 from the nurse's station.

14. An interview was conducted with the Nurse Manager on 6/23/21 at approximately 9:30 a.m. She stated, "Nursing staff has not told me they were having difficulty hearing the bed alarms. They did say sometimes the alarms wouldn't go off, but not complained they couldn't hear the bed alarms."

15. An interview was conducted with RN #2 on 6/23/21 at approximately 9:35 a.m. She stated, "Sometimes you can hear the bed alarms and sometimes you can't, it just depends." I couldn't hear the alarm standing by the room (room 202).

16. An interview was conducted with RN #3 on 6/23/21 at approximately 9:40 a.m. She stated, "If the door is shut you cannot hear the alarms."

17. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 6/23/21 at approximately 9:45 a.m. He stated, "If doors are shut you can't hear the alarms. You have difficulty if there is a lot of traffic on the floor. There is a lot of noise and it makes it difficult to hear the alarms."

18. A review of the hospital reporting system revealed a total of eleven (11) falls have occurred on the Surgical/Oncology floor since 1/1/21.

19. An interview was conducted with the Director of Performance Improvement and Quality on 6/23/21 at approximately 1:55 p.m. She concurred that nursing not being able to hear the bed alarms on the Surgical/Oncology Unit could be contributing to the high number of falls on that unit.