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Based on medical record review, review of hospital policy, and staff interview, the Acute Care Hospital's administrative staff failed to follow their policies to ensure hospital staff provide patient care in a safe setting. Failure to follow their policies resulted in the following:

1) Hospital staff not properly securing the patient during transport resulted in the occurrence of an otherwise preventable fall incident on hospital property, which had the potential to result in physical harm or death. (see A0144)

The cumulative effect of these systemic failures and deficient practices resulted in the Acute Care Hospital's inability to ensure patients receive care in a safe setting.

Based on observations, document review, and staff interviews, the Acute Care Hospital (ACH) failed to provide care in a safe setting to 1 of 20 patients (Patient #5). Failure to properly secure the patient during transport may result in the occurrence of an otherwise preventable fall incident on hospital property, which could result in physical harm or death. The Hospital's administrative staff identified a daily census of 796 inpatients on 6/17/24.

Findings include:

1. Review of policy, "Transport of Patients", last revised 6/2021, revealed in part: "...The Registered Nurse is responsible for determining the mode of transportation, equipment required, and the level and skill of staff required to provide nursing care ..."

2. During an interview on 6/26/24 at 11:00 AM, Registered Nurse (RN), Staff M explained, when they transferred Patient #5 to the Patient's customized wheelchair, a blanket was covering the seat and they did not see a seatbelt. Staff M (RN) explained they had taken care of Patient #5 in bed and did not know the patient's disability required a seatbelt in the wheelchair. Staff M (RN) reported they had not received any instruction on the proper way to secure Patient #5 in their wheelchair.

3. During an interview on 6/24/24 at 12:54 PM, Physical Therapist (PT) Staff D indicated the Physical Therapy department received a consult request from Physician U to evaluate and treat Patient #5. Staff D (PT) reported they did not recall a seatbelt in Patient #5's customized wheelchair and confirmed the initial physical therapy assessment revealed no documentation of Patient #5's seatbelt requirement.

4. During an interview on 6/25/24 at 11:15 AM, Physician E explained they performed brain surgery on January 5th, 2024 to repair Patient #5's malfunctioned shunt (a hollow tube surgically placed in the brain to help drain cerebrospinal fluid and redirect it to another location in the body where it can be reabsorbed). Physician E reported providers rely on the physical therapy staff to assess patients' mobility. Physician E denied ever ordering specific instructions for the use of personal equipment or placing orders for a seatbelt to be used for a custom wheelchair.

5. During an interview on 6/24/24 at 2:20 PM, Staff N (Transporter) explained nursing staff had placed Patient #5 in their personal customized wheelchair prior to Staff N (Transporter) arrival to the unit. Staff N (Transporter) reported Patient #5 was covered with blankets and no seatbelt was visualized. Staff N (Transporter) recalled when turning the wheelchair toward the transportation van, parked and waiting to transport Patient # 5 to home, a wheel of the customized wheelchair got caught in a small crack in the sidewalk and Patient #5 fell forward striking the head. Staff N (Transporter) called for help. Staff N, with the help of a bystander, placed Patient #5 back into the customized wheelchair and took the Patient back inside the hospital to the emergency department (ED) where Patient #5 was evaluated and re-admitted to the Hospital.

6. Review of Patient #5's medical record revealed:
a. On 1/6/24 at 1:13 PM, Staff D (PT) documentation revealed, "Patient #5 is non-ambulatory; the patient is able to stand and pivot to their customized wheelchair."

b. On 1/7/24 at 1:35 PM, Staff D (PT) documentation revealed, Patient #5 was able to move from "lying to sitting on the edge of the bed, stood, and transferred into the custom wheelchair." Patient #5 used "feet to propel the custom wheelchair."

7. .During an interview on 6/25/24 at 3:22 PM, the survey team interviewed Patient #5's mother/co-guardian via phone. The mother reported the Patient #5's customized wheelchair did not have foot pegs in order for the patient to maintain mobility using their feet. The mother reported prior to the hospital admission, it was easy for the Patient #5 to hold their feet up to be pushed, if needed. The mother further explained due to Patient #5's special needs, the "custom wheelchair had an obvious built-in strap that was always buckled across the patient's lap for safety and positioning."

The nursing staff failed to determine the appropriate mode of transportation to properly secure the patient during transport on 1/8/24, and Patient #5 sustained a fall with subsequent injuries.

Based on observations, document review, and staff interviews, the Acute Care Hospital (ACH) failed to ensure:

1) Hospital staff nursing supervision, assessment, and evaluation of unidentified new or existing health care conditions that could lead to prolonged illness or death for the patient. (see A0395)

The cumulative effect of these systemic failures and deficient practices resulted in the Acute Care Hospital's administrative staff's inability to ensure patients receive care in a safe setting.

Based on observations, document review, and staff interviews, the Acute Care Hospital (ACH) failed to ensure the nursing staff provided adequate supervision, assessment, and evaluation of care for 1 of 20 patients (Patient #5). Failure to adequately provide nursing supervision, assessment, and evaluation of care could result in unidentified new or existing health care conditions that could lead to prolonged illness or death for the patient. The Hospital's administrative staff identified a daily census of 796 inpatients on 6/17/24.

Findings include:

1. During an interview on 6/26/24 at 11:00 AM, Registered Nurse (RN) Staff M explained, when they transferred Patient #5 to the customized personal wheelchair, a blanket was covering the seat and they did not see a seatbelt. Staff M (RN) explained they had taken care of Patient #5 in bed and did not know the patient required a seatbelt when seated in the wheelchair. Staff M (RN) reported they had not received any instruction on the proper way to secure Patient #5 in their wheelchair.

2. During an interview on 6/24/24 at 2:20 PM, Staff N (Transporter) explained nursing staff had placed Patient #5 in their personal customized wheelchair prior to Staff N (Transporter) arrival to the unit. Staff N (Transporter) reported Patient #5 was covered with blankets and no seatbelt was visualized. Staff N (Transporter) recalled when turning the wheelchair toward the transportation van waiting to transport the patient home, a wheel of the customized wheelchair got caught in a small crack in the sidewalk and Patient #5 fell forward onto the sidewalk and struck his head. The Transporter Staff (Staff N) called for help. Staff N, with the help of a bystander, placed Patient #5 back into the customized personal wheelchair and took the Patient back inside the hospital to the Emergency Department where Patient #5 was examined and subsequently re-admitted to the hospital.

3. During an interview on 6/24/24 at 12:54 PM, Physical Therapist (PT) Staff D indicated the Physical Therapy department received a consult request from Physician U to evaluate and treat Patient #5. Staff D (PT) reported they did not recall a seatbelt in Patient #5's personal wheelchair and confirmed the initial physical therapy assessment revealed no documentation of Patient #5's seatbelt requirement.

4. Review of Patient #5's medical record revealed:
a. On 1/6/24 at 1:13 PM, Staff D (PT) documentation revealed, Patient #5 was "non ambulatory, but able to stand and pivot to the custom wheelchair."

b. On 1/7/24 at 1:35 PM, Staff D (PT) documentation revealed, Patient #5 was able to move from "lying to sitting on the edge of the bed, stood, and transferred into the custom wheelchair." Patient #5 used their feet to propel the custom wheelchair.

5. During an interview on 6/25/24 at 3:22 PM, the survey team interviewed the Patient #5's mother/co-guardian via phone. The mother reported the Patient #5's custom "hemi wheelchair did not have foot pegs" in order for the patient to move the wheelchair using their feet. The mother reported prior to the hospital admission, it was easy for the Patient #5 to hold their feet up to be pushed, if needed. The mother further explained due to Patient #5's special needs, the "custom wheelchair had an obvious built-in strap that was always buckled across the patient's lap for safety and positioning."

The nursing staff failed to properly secure Patient #5 in the customized personal wheelchair for the Patient's transport on 1/8/24. Patient #5 sustained a fall during the transport that resulted in injuries. The fall from the customized personal wheelchair and associated injuries required evaluation in the emergency department and Patient #5 was subsequently re-admitted to the hospital.