HospitalInspections.org

Based on the seriousness of the non-compliance and the potential effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.13 Tag A-0131

The information reviewed during the survey provided evidence the facility failed to obtain the advance directive of one of one medical record reviewed (MR1) and failed to ensure the Patient's Representative was provided the right to make informed decisions regarding care for one of one MR reviewed (MR1).

482.13 Tag A-0144

The information reviewed during the survey provided evidence the facility failed to ensure care in a safe setting by failing to implement emergency procedures without delay in one of one medical record (MR1).

482.13 Tag A-0168

The information reviewed during the survey provided evidence the facility failed to ensure a provider order was obtained for the use of restraint in one of three medical records reviewed (MR4).

482.13 Tag A-0172

The information reviewed during the survey provided evidence the facility failed to ensure documentation of provider reassessment of the need to continue the use of restraints in two of three MRs reviewed (MR5 and MR6).

482.13 Tag A-0196

The information reviewed during the survey provided evidence the facility failed to ensure nursing staff involved in patient care demonstrated competency in the use of restraint in seven of seven personnel files (PF) reviewed (PF1, PF2, PF3, PF4, PF5, PF6 and PF7).

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP2, EMP3, EMP4, EMP5 and EMP13) regarding the survey team's concerns related to Patient's Rights on September 30, at 0905.


Cross reference
482.13 (b)(2) Patient Rights: Informed Consent
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.13(e)(5) Patient Rights: Restraint or Seclusion
482.13(e)(8) Patient Rights: Restraint or Seclusion
482.13 (f)(1) Patient Rights: Restraint or Seclusion

Based on review of facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to follow facility approved policy to obtain the advance directive of one of one MR reviewed (MR1) and failed to ensure the Patient's Representative was provided the right to make informed decisions regarding care for one of one MR reviewed (MR1).

Findings include:

Review on September 29, 2022, of facility policy "Advance Directives - Organizational Wide Policy," published on September 27, 2022, revealed "...Procedures: ...2. General Information Information Regarding Advance Directives... b) It is the responsibility of the patient's attending physician to be aware of the patient's wishes as outlined in the advance directive, to comply with Pennsylvania state law regarding advance directives and to then determine the course of treatment. c) Nursing Staff addresses advance directives with patients during the initial nursing assessment. All patients (or their Health Care Representatives, as applicable) will be asked if they have an advance directive upon admission. If the patient has an advance directive, a copy is requested for the chart. If a patients [sic] has an advance directive, but it is not with the patient at the time of arrival, nursing staff shall request the name and contact information for the person or persons who will be requested to bring a copy of the advance directive for inclusion in the patient chart. ...3. Special Situations...b) Where a clear and convincing advance directive is not present or where the validity of the directive is questionable, all appropriate measures will be provided to the patient unless a Health Care Representative, acting on behalf of the patient under Pennsylvania Law ACT 169 of 2006, determines that the treatment would not reflect the patient's wishes or best interest. ..."

Review of MR1 on September 29, 2022, revealed documentation in the initial nursing assessment which indicated MR1 had an advance directive. There was no advance directive in MR1 and no documentation of the name and contact information for the person who was or would be requested to bring a copy of the advance directive.

Interview with EMP4 on September 29, 2022, at approximately 1015, confirmed there was no documentation of the name and contact information for the person who was requested to bring a copy of the advance directive.

Interview with EMP4 on September 30, 2022, at 1522, confirmed a search by health information services revealed there was no advance directive in MR1.

Continued review of MR1 revealed, upon admission on September 21, 2022, EMP10 ordered and documented MR1 was a full code (all emergency measures to be taken in the event of a cardiac or respiratory arrest). After MR1 suffered a cardiac arrest on September 23, 2022, EMP10 changed the code status to a modified code (no chest compressions). There was no documentation of a discussion with MR1's representative or consent of the representative to change the code status.

Interview with EMP10 on September 29, 2022, at 1400 confirmed, following the cardiac arrest, MR1 was in cardiogenic shock and a discussion was held with the daughter concerning MR1's prognosis and code status. EMP10 revealed the daughter had called back and consented to the change in code status, but s/he did not document the family's wishes in MR1.

Based on review of facility policy, documentation, and medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure care in a safe setting by failing to implement emergency procedures without delay in one of one MR (MR1).

Findings include:

Review on September 29, 2022, of facility policy "Patient Rights & Responsibilities," published on September 28, 2022, revealed "Purpose: This policy is to define the rights of patients at Evangelical Community Hospital and entities. ...Patient Rights & Responsibilities: ...Care Delivery You have the right to: Expect emergency procedures to be implemented without unnecessary delay. ..."

Review of facility documentation of a text log for September 23, 2022, produced by Information Technology on September 30, 2022, revealed a text from EMP11 to EMP8 at 1204 and two texts to EMP8 from EMP9 at 1212.

Review of MR1 on September 29, 2022, revealed the Rapid Response Team (RRT) was called at 1223 on September 23, 2022, when MR1 was found on the floor unresponsive. A code for cardiac arrest was called at 1226.

Interview with EMP11 on September 30, 2022, at 1034 revealed on September 23, 2022, at approximately noon, a lost signal alarm sounded in the telemetry control room for MR1. EMP11 revealed s/he "gave it a minute" and at 1204 texted EMP8 to alert her/him. EMP11 confirmed s/he waited five minutes and at 1209 called the unit and spoke with EMP9 on the nursing unit to check if MR1 was off the unit. EMP11 revealed EMP9 stated s/he would check with EMP8.

Interview with EMP9 on September 29, 2022, at 1500 revealed s/he spoke with EMP11 sometime around noon on September 23, 2022. EMP9 revealed s/he was asked by EMP11 if MR1 was off the unit since a lost signal alarm was sounding. EMP9 confirmed s/he would check with EMP8 and then texted EMP8.

Interview with EMP8 on September 29, 2022, at 1425 revealed s/he had not heard any text alerts while performing the skin assessment in another room. EMP8 first learned that MR1 was in distress when s/he exited another patient room and noticed commotion outside of MR1's room. EMP8 confirmed when entering the room, MR1 was on the floor with her oxygen removed and the cord that plugs into the telemetry box dangling between her legs under her gown. EMP8 further confirmed it was unknown how long MR1 was in distress before being found unresponsive.

Based on review of facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure an order for restraint was obtained for non-violent restraint use in one of three MRs reviewed (MR4).

Findings include:

Review on September 30, 2022, of facility policy, "Physical Restraints/Chemical Restraints," last reviewed April 4, 2022, revealed "Purpose: The purpose of this policy it to 1. prevent interference/obstruction with medical treatments (such as self extubation and intubation). 2. protect medical devices (such as intravenous lines, in-dwelling urinary catheters, and feeding tubers). 3. prevent falls and injury. 4. control disruptive behavior (such as agitation, wandering, and combativeness). 5. preclude the possibility of harming self, staff and other patients ... Procedures: ... 2. Use of Restraints in Medical or Post-Surgical Care: a) When clinically indicated, the restraint procedure is implemented by an RN who is trained in restraint technique upon a physician's/L.I.P. order. Physician/L.I.P. may delegate ordering restraint to physician assistant or advance practice nurse in both behavioral health and acute care non-behavioral health care settings. ...d) A restraint order expires after 24 hours and must be reordered if restraints continue to be required. ..."

Review on September 29, 2022, of MR4, revealed the patient had bilateral soft wrist restraints in place on April 30, 2022, beginning at 1900, and discontinued on May 1, 2022, at 0530. There was no documentation of an order for restraints.

Interview with EMP5 on September 29, 2022, at 1350, confirmed MR4 had bilateral soft wrist restraints in place on April 30, 2022, beginning at 1900 and discontinued on May 1, 2022, at 0530. EMP5 confirmed MR4 had no order for restraints.

Based on review of facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure documentation of provider reassessment of the need to continue the use or restraint in two of three MRs reviewed (MR5 and MR6).

Review on September 30, 2022, of facility policy, "Physical Restraints/Chemical Restraints," last reviewed April 4, 2022, revealed "Purpose: The purpose of this policy it to 1. prevent interference/obstruction with medical treatments (such as self extubation and intubation). 2. protect medical devices (such as intravenous lines, in-dwelling urinary catheters, and feeding tubers). 3. prevent falls and injury. 4. control disruptive behavior (such as agitation, wandering, and combativeness). 5. preclude the possibility of harming self, staff and other patients...Procedures: ...2. Use of Restraint in Medical or Post-Surgical Care:...d) A restraint order expires after 24 hours and must be reordered if restraints continue to be required....4. Implementation: ...b) Patients in restraints will be assessed, monitored, and re-evaluated for appropriateness of an early release. ..."

Review on September 29, 2022, of MR5 revealed the patient had bilateral soft mitt restraints in place September 16, 2022, beginning at 2205 and discontinued on September 18, 2022, at 0800. There was no documentation of provider reassessment every 24 hours while the patient was in restraints.

Interview with EMP5, on September 29, 2022, at 1430, confirmed MR5 had bilateral soft mitt restraints in place on September 16, 2022, beginning at 2205 and were discontinued on September 18, 2022, at 0800. EMP5 confirmed there was no documentation of provider reassessment every 24 hours while the patient was in restraints.

Review on September 29, 2022, of MR6 revealed the patient had bilateral soft wrist restraints in place September 16, 2022, beginning at 0516 and discontinued on September 19, 2022, at 0739. There was no documentation of provider reassessment every 24 hours while the patient was in restraints.

Interview with EMP5 on September 29, 2022, at 1510, confirmed MR6 had bilateral soft wrist restraints in place on September 16, 2022, beginning at 0516 and discontinued on September 19, 2022, at 0739. EMP3 confirmed there was no documentation of provider reassessment every 24 hours while the patient was in restraints.

Based on review of facility policy, personnel files (PF) and staff (EMP) interview, it was determined the facility failed to ensure nursing staff members who provide direct patient care demonstrated annual competency in the use of restraints in seven of seven personnel files reviewed (PF1, PF2, PF3, PF4, PF5, PF6 and PF7) for two of two years reviewed (2021 and 2022).

Findings include:

Review on September 30, 2022, of facility policy "Physical Restraints/Chemical Restraints," effective April 4, 2022, revealed "...Procedures: ...3. Staff Competency: a) Nursing staff members who have direct patient care contact will have education and training regarding the use of restraints at orientation and annually as part of a competency evaluation. ..."

Review on September 30, 2022, of seven PFs (PF1, PF2, PF3, PF4, PF5, PF6, and PF7) of registered nurses (RNs) and nursing assistants (NAs) involved in the care of MR1 revealed there was no documentation of an annual competency evaluation of the use of restraints for 2021 and 2022.

Interview with EMP2 on September 30, 2022, at 1517 confirmed PF1, PF2, PF3, PF4, PF5, PF6, and PF7 did not have annual competency evaluation in the use of restraints in 2021 and 2022. EMP2 further confirmed the facility does not have a process to perform annual competency evaluations for the use of restraint for staff members involved in direct patient care.

Based on the seriousness of the non-compliance and the potential effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.23 Tag-0398

The information reviewed during the survey provided evidence the facility failed to ensure staff followed approved policies for development of a nursing plan of care for patients at risk for fall in one of two MRs reviewed (MR3); pain reassessment in four of seven MRs reviewed (MR1, MR2, MR3 and MR7); administration of pain medication in one of one MR (MR1); documentation of a serious event disclosure in one of one MR (MR1), and; sequestering equipment involved in a serious event.

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP2, EMP3, EMP4, EMP5 and EMP13) regarding the survey team's concerns related to Patient's Rights on September 30, at 1615.


Cross reference
482.23 (b)(6) Supervision of Contract Staff

Based on review of facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure staff followed approved policies for development of a nursing plan of care for patients at risk for fall in one of two MRs reviewed (MR3); pain reassessment in four of seven MRs reviewed (MR1, MR2, MR3 and MR7); administration of pain medication in one of one MR (MR1); documentation of a serious event disclosure in one of one MR (MR1), and; sequestering equipment involved in a serious event.

Findings include:

Review on September 30, 2022, of facility policy, "Documentation," last reviewed November 2, 2021, revealed "Purpose: Nursing Policies exist to provide a general conduct of care and compliance with acceptable Nursing standards and regulations. Policy: All patients shall receive nursing care based on the nursing process which is documented as part of the patient's permanent record. Procedures: 1. Each patient's need for nursing care related to his/her admission shall be assessed by an RN upon admission. ... 5. Each inpatient is required to have a patient care plan. 6. Patient care plan will include: a) Patient's problems/needs and/or Nursing Diagnosis b) Nursing actions c) Evaluation of patient progress and/or resolution of identified problems/needs. d) Patient outcomes..."

Review on September 30, 2022, of facility acceptable Nursing standard, "Workflow for Fall Risk Assessment," revealed, "Purpose To identify patients that area a high risk for fall injuries. To implement appropriate precautions to help prevent falls. ... Interventions to bed used based on scoring: Low Risk 0-35 Implement standard fall precautions. Moderate Risk 36-50, Non-PRIME Units: Implement standard fall precautions; Pull fall packet; if mental status of 15 and/or a fall (History of Falling) score 25, must use a bed alarm and patient must be within arm's reach when ambulation or using bathroom. Moderate Risk 36-50, PRIME Units: Implement standard fall precautions; Initiate care plan if not already done. Indicate falling person symbol outside door, personal alarm reminder on whiteboard in red. If mental status of 15 and/or a fall score 25 (History of Falling), must use bed alarm and patient must be within arm's reach when ambulating or using bathroom. ...If you identify a patient as a Fall Risk: 1. Place fall risk band on patient. 2. Initiate Care Plan for Fall Prevention. 3. Implement Fall Prevention Interventions as indicated."

Review on September 29, 2022, of MR3 revealed documentation of Fall Risk Assessment score of 35-45, with interventions of a fall risk band, assistive devices, bed in low position, call bell/light in reach, belongings in easy reach and sufficient lighting. Further review of MR3 revealed no care plan for fall prevention.

Interview with EMP 5 on September 29, 2022, at 1020 confirmed MR3 had a Fall Risk Assessment score of 35-45 with interventions of a fall risk band, assistive devices, bed in low position, call bell/light in reach, belongings in easy reach and sufficient lighting. EMP5 confirmed MR3 had no care plan for fall prevention.

Review on September 29, 2022, of facility policy "Medication Administration," last revised November 26, 2018, revealed "Procedures: ...3. Charting - In Areas Using Scanning ...f) Pain Control Effectiveness i. The effectiveness of pain medication administration of a one-time or an as needed (prn) dose will be assessed and documented within one hour. ..."

Review on September 29, 2022, of MR1 revealed the patient received hydromorphone IV on September 22, 2022, at 1455 for a pain scale of 10. At 1530 a pain reassessment was documented as "task completed". There was no documentation of a pain scale or a note to indicate pain was or was not relieved. MR1 received oxycodone 5 mg po at 1612 for a pain scale of 5. Pain reassessment was completed within one hour and documented as "task completed". There was no documentation of a pain scale or a note to indicate pain was or was not relieved.

Interview with EMP2 on September 29, 2022, at 1107 confirmed the pain reassessment tasks were documented as completed, but did address the effectiveness of the pain medication.

Review on September 29, 2022, of MR2 revealed the patient received Oxycodone 10mg on September 29, 2022, at 0050 for a pain scale of 7. At 0130 a pain reassessment was documented as "task completed". There was no documentation of a pain scale or a note indicating pain was or was not relieved.

Interview with EMP5, on September 29, 2022, at 1100 confirmed MR2 received Oxycodone 10mg on September 29, 2022, at 0050, for a pain scale of 7. At 0130 a pain reassessment was documented as "task completed". There was no documentation of a pain scale or a note indicating pain was or was not relieved.

Review on September 29, 2022, of MR3, revealed the patient received Tylenol 650 mg on September 28, 2022, at 2217, for a pain scale of 3. At 2300 a pain reassessment was documented as "task completed". There was no documentation of a pain scale or a note indicating pain was or was not relieved.

Interview with EMP5, on September 29, 2022, at 1145, confirmed MR3 received Tylenol 650 mg on September 28, 2022, at 2217, for a pain scale of 3. At 2300 a pain reassessment was documented as "task completed". There was no documentation of a pain scale or a note indicating if the pain was or was not relieved.

Review on September 30, 2022, of MR7, revealed the patient received Tylenol with Oxycodone (325mg/5mg) on September 23, 2022, at 1754 for a pain scale of 9. At 1822 a pain reassessment was documented as "task completed". There was no documentation of a pain scale or a note indicating pain was or was not relieved. MR7 received Tylenol with Oxycodone (325mg/5mg) on September 25, 2022, at 1957, for a pain scale of 8. There was no documentation of pain reassessment within one hour. MR7 received Tylenol with Oxycodone (325mg/5mg) on September 27, 2022 at 1038 for a pain scale of 9. There was no documentation of a pain reassessment within one hour. MR7 received Tylenol with Oxycodone (325mg/5mg) on September 29, 2022 at 0548 for a pain scale of 7. There was no documentation of a pain reassessment within one hour. MR7 received Tylenol with Oxycodone (325mg/5mg) on September 30, 2022 at 0643 for a pain scale of 9. There was no documentation of a pain reassessment within one hour.

Interview with EMP5 on September 30, 2022, at 1115, confirmed MR7 received Tylenol with Oxycodone (325mg/5mg.) on September 23, 2022, at 1754 for a pain scale of 9. At 1822 a pain reassessment was documented as "task completed". There was no documentation of a pain scale or a note indicating pain was or was not relieved. MR7 received Tylenol with Oxycodone (325mg/5mg) on September 25, 2022, at 1957 for a pain scale of 8. There was no documentation of pain reassessment within one hour. MR7 received Tylenol with Oxycodone (325mg/5mg) on September 27, 2022 at 1038 for a pain scale of 9. There was no documentation of a pain reassessment within one hour. MR7 received Tylenol with Oxycodone (325mg/5mg) on September 29, 2022 at 0548 for a pain scale of 7. There was no documentation of a pain reassessment within one hour. MR7 received Tylenol with Oxycodone (325mg/5mg) on September 30, 2022 at 0643 for a pain scale of 9. There was no documentation of a pain reassessment within one hour.

Review on September 29, 2022, of facility policy "Medication Administration," last revised November 26, 2018, revealed "Procedures: ...2. Medication Administration-Schedule ...b) Variable Schedule and Dose-Analgesic Orders i. In the scenario where the nurse administers a dose of one tablet and then receives a request from the patient an hour later for an additional analgesic. We incorporate the half time rule into the procedure for handling these types of orders. The half time rule would dictate that if one tablet was administered for the initial dose and patient requires the other (l) tablet within the first half of the dose interval, it could be administered by the nurse without contacting the prescriber. The next dose can be administered 4 hours after the first dose. ...iii. Variable dose orders are only permitted on oral analgesics. ..."

Review on September 29, 2022, of MR1 revealed orders for the following pain medications: hydromorphone 0.25mg intravenous (IV) every two hours prn for a severe pain scale of 8-10, oxycodone 10 mg po (by mouth) every four hours prn for a pain scale of 8-10, and oxycodone 5mg po every four hours prn for a pain scale of 5-7. MR1 received hydromorphone 0.25mg IV on September 22, 2022, at 1455 for a pain scale of 10. At 1612 MR1 received oxycodone 5 mg po for a pain scale of 5.

Interview with EMP2 on September 29, 2022, at 1107 confirmed hydromorphone IV and oxycodone po were given within 77 minutes.

Interview with EMP7 on September 29, 2022, at 1135 confirmed variable dosing was for oral pain medications only. EMP7 revealed the facility did not have a policy to determine when a po pain medication could be administered if pain was still present after administration of an IV pain medication.

Review on September 29, 2022, of the facility "Patient Safety Plan," last reviewed June 28, 2022, revealed "...Definitions: ... Serious Event - An event, occurrence, or situation involving the clinical care of a patient in a medical facility (hospital, ambulatory surgery facility, or birthing center) that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health services to the patient. ...Scope and Components of the Program...Disclosure - Patients, and when appropriate, their families will be informed by the attending physician, or his/her designee, involved in the care of that patient about the outcomes of care, including unanticipated outcomes. At least one hospital representative may be present at the time of the disclosure. The physician, or his/her designee, will clearly explain the unanticipated outcome to the patient and/or family members as soon after the event or incident as is possible and appropriate. ..."

Review on September 29, 2022, of facility policy "Disclosures of Unanticipated Outcomes," last reviewed March 24, 2022, revealed: "Purpose: The purpose of this policy is to define the procedure for communicating and documenting disclosure with patients and their families following an unanticipated outcome. ...Procedures: ...3. Disclosure-What should be disclosed a. An apology without laying blame or fault b. Nature of the event as it is understood at the time of the conversation c. The time, place and circumstances of the event or accident as understood at the time of the conversation d. The known, definite consequences of the accident to the patient and potential or anticipated consequences e. Actions taken to treat or ameliorate the consequences of the accident or event f. Who else has been informed of the unanticipated event (in the hospital, regulatory agencies, etc.)? g. The actions that have been or will be taken to identify process issues which may have contributed to the accident or event and to prevent the same or similar situations from occurring. h. Who will manage ongoing communication with the family? i. The names and phone numbers of individuals in the hospital to whom the patient, family or legal guardian/surrogate may address complaints or concerns? j. Information on how to obtain support and counseling regarding the event and its consequences, both within the facility and from outside resources as appropriate. k. Offer of support and availability to answer additional questions... 5. Documentation of Disclosure- The following information should be documented in the medical record: a. Time, date, and place of the discussion b. Name and relationship of all persons present during the discussion c. Nature of the event and review of the unanticipated outcome d. Documentation of an offer of support or assistance and the response e. Consultations with those providing psychiatric or ethics evaluations should be recorded in accordance with facility policy f. Any follow up discussions should be documented including time, date, place, names, and relationships of those present g. Additional information as appropriate to the situation... Responsibilities: Quality, Patient Safety and Risk Management Department will have overall responsibility for the implementation of this policy. When to disclose - Disclosure shall be made as soon as practical and in the best interest of the patient. ... Definitions: ...5. Patient Safety Event - Any near miss event, medical accident, serious event, significant procedural variance, or other possible threat to safety. ... "

Review of MR1 on September 29, 2022, revealed on September 23, 2022, at noon, EMP8 documented MR1 was in bed with alarm in place. At 1217 MR1 was found by the OTH1 on the floor and called for help. EMP8 called the Rapid Response Team (RRT) at 1223 and a code for cardiac arrest was called at 1226. MR1 was resuscitated and transferred to the intensive care unit. MR1 expired at 2231 on September 23, 2022.

Interview with EMP11 on September 30, 2022, at 1034 revealed on September 23, 2022, at approximately noon, a lost signal alarm sounded in the telemetry control room for MR1. EMP11 revealed s/he "gave it a minute" and at 1204 texted EMP8 to alert her/him. EMP11 confirmed s/he waited five minutes and at 1209 called the unit and spoke with EMP9 on the nursing unit to check if MR1 was off the unit. EMP11 revealed EMP9 stated s/he would check with EMP8.

Interview with EMP9 on September 29, 2022, at 1500 revealed s/he spoke with EMP11 sometime around noon on September 23, 2022. EMP9 revealed s/he was asked by EMP11 if MR1 was off the unit since a lost signal alarm was sounding. EMP9 confirmed s/he would check with EMP8 and then texted EMP8.

Interview with EMP8 on September 29, 2022, at 1425 revealed s/he had not heard any text alerts while performing the skin assessment in another room. EMP8 first learned that MR1 was in distress was when s/he exited another patient room and noticed commotion outside of MR1's room. EMP8 confirmed when entering the room, MR1 was on the floor with her oxygen removed and the cord that plugs into the telemetry box dangling between her legs under her gown. EMP8 further confirmed the bed alarm was not alerting and it was unknown how long MR1 was in distress before being found unresponsive.

Review on September 29, 2022, of MR1 revealed there was no documentation present of disclosure to the family of the serious event (i.e., the delay in response to the telemetry alarm and the failure of the bed alarm) and the outcome.

Interview with EMP4 on September 29, 2022, at 1339 confirmed the event was classified as a serious event. EMP4 further confirmed there was no disclosure to the family of the circumstances surrounding the serious event that may have contributed to the adverse outcome for MR1.

Review on September 29, 2022, of facility policy "Custody of Devices," published on July 11, 2022, revealed "Purpose: To outline procedures for devices or equipment needing to be sequestered in the event of a medication or medical device error. Policy: Medical devices, and medications which may have contributed to an incident will be isolated and preserved as evidence until an appropriate investigation is performed by the Risk staff, or Quality Improvement and Patient Safety Director. ..."

Interview with EMP8 on September 29, 2022, at 1425 revealed when s/he had glanced in MR1's room and saw the patient in bed s/he had "assumed" the bed alarm was set. EMP8 confirmed s/he did not place MR1 in bed. EMP8 further confirmed when s/he was called to the room MR1 was found on the floor and the bed alarm was not alerting. EMP8 was unable to definitively confirm the bed alarm was on and functioning prior to the event.

Interview with EMP8 on September 29, 2022, at approximately 1400, confirmed since it was unknown if the bed alarm was not on or if it was on and not functioning the bed should have been sequestered following the event and until a determination could be made.