HospitalInspections.org

Based on observation, interview and record review, the hospital failed to comply with the Condition of Participation (CoP) for Patient Rights as evidenced by:

The hospital failed to provide safe patient care to one of 30 sampled patients (Patient 24), when the hospital failed to ensure a gurney was used according to manufacturer recommendations. This failure resulted in Patient 24 sustaining multiple injuries as a result of a fall from the gurney onto the floor during transportation to a mobile MRI (Magnetic Resonance Imaging) trailer (refer to A-0144).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on observation, interview and record review the hospital failed to provide safe patient care to one of 30 sampled patients (Patient 24), when the hospital failed to ensure a gurney was used according to manufacturer recommendations. This failure resulted in Patient 24 sustaining multiple injuries as a result of a fall from the gurney onto the floor during transportation to a mobile MRI (Magnetic Resonance Imaging) trailer.

Findings:

During an interview on 1/13/25, at 9:40 a.m., with Imaging Director (ID) ID stated, he was notified of a fall that occurred on 12/28/24 in the MRI trailer located at the facility's ambulance bay. ID stated, Patient 24 was transported from his unit in the facility to the MRI trailer by Patient Transporter A (PT A). ID stated, when Patient 24 arrived to the MRI trailer, MRI Technician B (MT B) helped transfer the patient from his hospital bed gurney to the MRI safe gurney located outside the MRI trailer. ID stated, according to the rapid response nurse notes, the patient fell onto the floor of the lift (that takes the patient up the to level of the MRI trailer) from the gurney, as the MT B was attempting to bring the gurney inside the trailer from the lift.

During a review of Patient 24's "Orders," dated 12/26/24, the orders indicated an order for MRI Brain... Reason for exam: worsened arousal and mental status, recent CVA (stroke, cerebral vascular accident) and gliosarcoma (brain cancer).

During a review of a "RRT [Rapid Response Team] Activation and Response" document for Patient 24, dated 12/28/24, it indicated, Patient 24, "sustained fall from MRI gurney to floor of MRI trailer. It was reported that patient fell on front of his body... Abrasions to nose, bilateral arms, knees and toes. Patient is on blood thinner. ER staff initially assisted patient and staff... Stat CT head completed".

During a review of Patient 24's "CT [computerized x-ray imaging procedure] Maxillofacial Final Report," dated 12/29/24, it indicated, "Reason for exam fall,. . . Impression: 1. Bilateral nasal bone fractures with mild displacement. 2. Nasal Spine fracture".

During an interview on 1/13/25, at 2 p.m., with PT A, PT A stated, she was the transporter who brought Patient 24 from his unit in the facility to the MRI trailer located outside the facility in the ambulance bay on 12/28/24. PT A stated she used the patient's hospital gurney to transport the patient outside the facility to the MRI trailer, then MT B assisted her in transferring the patient to the MRI safe gurney. PT A stated she and MT B placed the MRI safe gurney with the patient laying on his back onto the lifting platform to bring the patient from the ground level to the height of the MRI trailer. PT A stated MT B operated the lift with the patient, while she walked up the stairs to remove her metal objects before entering the MRI trailer scan area. PT A stated, while assisting MT B with moving the gurney off the lift platform and onto the MRI trailer there is a little bump, and when she was trying to help move the gurney into the trailer, the patient moved, "he kind of put his weight on one side of the bed and it was too small, the rails on the bed, he flipped and fell". PT A stated after the fall she called the emergency department staff and they responded immediately.

During an interview on 1/14/25, at 10:05 a.m., with MT B, MT B stated, he was the MRI Technician working at the MRI trailer on 12/28/24. MT B stated, he saw PT A arrive with Patient 24 to the MRI trailer, together they transferred Patient 24 from his bed gurney to the MRI safe gurney because the MRI trailer was higher than the ground, they had to use the lift platform to lift the patient to the same level as the trailer. MT B stated, "the gurney has a left and right side rail which were lifted up, but they are very low, they will not reach the height of the patients [Patient 24's] belly. There was an unanticipated motion from the patient so he was turning to his right side and because he turned, he toppled over the hand rail, because the hand rail is so low and he fell face down onto the stage [lift platform]". MT B stated, he informed his supervisor one month before this fall he was concerned the gurney didn't have any straps to hold the patients in place. MT B stated, "I expressed my concern about the gurney not having straps".

During an observation on 1/14/25 at 12:20 p.m., the hospital's MRI safe gurney was observed. MRI safe gurney indicated, it was manufactured by Ferno, with a model named Model 35x PROFlexx.

During a review of "User's Manual" for Ferno Model 35x Series PROFlexx gurney, undated, it indicated, "Warning... Improper use of the cot [gurney] can cause injury. Use the cot only for the purpose described in this manual... An unrestrained patient can fall off the cot and be injured. Use restraints to secure the patient to the cot... Included with purchase... set of 3 restraints... Standard features All cots are built with the following features... Restraints (set of 3)... Restraints, Mattress and Accessories... Before placing the cot in service assign appropriate personnel to install the mattress, restraints".

During a review of Patient 24's "History & Physical [H&P]," dated 12/28/24, it indicated, Patient 24 was transferred to the Intensive Care Unit after his fall at the MRI trailer. It indicated, "Chief Complaint Closed head injury after accidental fall... Problem List: A Left-sided soft tissue injury secondary to fall... Unfortunately before patient [Patient 24] was able to enter scanner [MRI], because of complications moving him into the portable unit, apparently fell to ground level from the gurney, falling face first, sustaining some soft tissue trauma... the patient was transferred to the medicine service with admission to the intensive care unit for further neurological checks".

During an interview on 1/15/25, at 12:30 p.m., with Staffing Manager (SM) C, SM C stated, he is the manager for staffing employees who work in the MRI trailer. SM C stated, the company he works for provided the MRI safe gurney to the facility for use in the MRI trailer, and the gurney was delivered brand new to the MRI trailer some time in the middle of 2024. SM C stated, he was informed about the fall that occurred on 12/28/24 by ID. SM C stated, he made a visit to the MRI trailer on either 12/29/24 or 12/30/24. SM C stated, straps were installed onto the gurney on one of those dates. SM C stated, he was unsure why the straps/restraints were not installed prior to first use of the gurney.