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VAN MATRE ENCOMPASS HEALTH REHABILITATION INSTITUT
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, it was determined for 1 of 1 (Pt. #1) patient with a wheelchair alarm ordered, the Hospital failed to ensure the wheelchair alarm was being used as ordered.
Findings include:
1. The Hospital policy titled, "Chair Monitoring System "Care Sense" (revised 08/15)" was reviewed on 4/27/16. The policy required, "Documentation: Status of chair check should be documented when nurse is rounding".
2. The clinical record of Pt. #1 was reviewed on 4/27/16. Pt. #1 was an 83 year old male admitted on 3/21/16 with the diagnosis CVA (cerebrovascular accident - stroke). The clinical record included a physician's order dated 3/21/16 at 4:51 PM for "Seat belt alarm when in wheelchair". The nursing rounding sheets dated 3/22/16 at 7:00 AM through 3/22/16 at 8:00 PM included that Pt. #1 was in the wheelchair; however, there was no documentation of the seat belt alarm. It could not be determined if the alarm was in use for those 13 hours.
3. During an interview on 4/28/16 at approximately 10:30 AM, the Chief Nursing Officer (E#2) stated, "The nurse should be checking on the alarm usage and documenting the use in the rounding notes".