HospitalInspections.org

Based on interview and document review, the facility failed to ensure nursing staff implemented safety measures to prevent falls for 1 (#1) of 10 patients reviewed for nursing services out of a total of 10 sampled patients, resulting in the potential for reoccurrence. Findings include:

On 2/21/18 at 1100 a tour of the perioperative nursing unit was conducted. An interview with Clinical Manager Staff E was conducted on on 2/21/18 at 1115. She (Staff E) explained she had been in her current role since the Fall of 2017. When queried regarding patient falls she explained it was possible. She said some patients at times may have felt that they were up to par for discharge and may have stumbled. She said that to her knowledge no one had fallen or suffered any injuries post-op. Staff E was asked to explain the facility's process for screening for specialty bed (bariatric) weight requirements (greater than 500 pounds).

According to Staff E the specialty beds were ordered the day before the patients scheduled surgery as requested by the surgeon to ensure that the appropriate bed was available. Staff E said the patients were transferred to the specialty bed from the stretcher in the PACU (post-anesthesia care unit). When asked to clarify at what point the patient would be placed or assisted to a specialty bed, Staff E repeated the transfer would occur in the PACU and not the Pre-OP (pre-operative) holding area.

When asked to explain the ratio of nurse to patient Staff E said they followed Aspan (American Society of Perianesthesia Nurses) guidelines for staffing. She said it was usually 2:1. When further queried Staff E said there had not been any falls on her unit to her knowledge.

On 2/21/18 at approximately 1500 a review of the medical record for patient #1 was conducted with Staff D and the following was documented:
According to the admission face sheet patient #1 was a same day admission for an Out-Patient surgical procedure (laryngoscopy with steroid injection). The patient's diagnoses included subglottic stenosis, angina pectoris and fall, initial encounter.

A review of a "Patient Safety Reporting (PSR)" document dated 8/29/17 documented:
The patient was transferring from stretcher to bed. Patient decided to slide over instead of standing to transfer. Curtain was closed. Heard call for help and patient was sitting on the floor. The patient complained of shoulder discomfort. Surgeon and Anesthia provider notified at bedside. Patient to OR in no apparent distress.

On 2/22/18 at 0930 an interview was conducted with the previous Nurse Manager for the Perioperative Unit Staff H. When queried regarding the patient (#1's) fall on 8/29/17, Staff H explained she did not recall if she was notified about the fall on the day of or the day after the patient fell. When asked to explain if she interviewed any staff or the patient about the fall Staff H said she did not recall. When asked to explain who was assigned to care for the patient that day Staff H said "both nurse's are not available". When asked to explain if it was routine that patient's were left unattended to transfer from a stretcher to a specialty bed Staff H said that was not the routine. She said any 1 of 10 to 20 Patient Care Technicians (PCT's) would be available to assist the patient with transferring from one bed to another.

On 2/22/18 at 1120 an interview was conducted with Nurse Assistant Staff K. Staff K was asked if she recalled patient #1 and the incident (fall) that occurred 8/29/17. Staff K said she was only asked about the patient a few weeks ago. When further queried regarding the patient's fall, Staff K explained she present when the patient fell. She said the patient was in Pre-OP and when prompted to slide from the stretcher to the specialty bed the patient fell in between the stretcher and the specialty bed. Staff K said she recalled asking other team members if the bed was locked. Staff K said the specialty bed was not locked during the transfer and as a result the patient landed hard on her upper hip and lower leg. Staff K said she could only recall the name of one nurse who was present during the incident. When further queried Staff K explained she had not received any re-education or counseling on preventing patient falls.

On 2/22/18 at 1240 a review of the incident/accident (PSR) for patient #1 was reviewed with the Director of Patient Relations Staff L. According to the PSR report the patient (#1's) fall occurred in the Pre-OP holding area on 8/29/17. The time listed for the fall was "between 1300-1400". There was no exact time listed. It was documented that the patient's fall was not witnessed. There was no further evidence that documented the facilty interviewed the patient or the assigned team members following the incident.

On 2/22/18 at 1300 during an interview Staff D was asked to provide evidence of corrective measures that were implemented to decrease the risk of reoccurence Staff D explained there was none.