HospitalInspections.org

A. Based on document review, observation, and interview it was determined that for 3 of 3 patients (Pts. #1, #2, and #10) reviewed for fall prevention, the Hospital failed to ensure that patients at risk for falls were supervised by nursing staff by failing to ensure that staff followed the Hospital's fall prevention polices, as required.

Findings include:

1.The Hospital's policy, titled "Fall Prevention for Hospitalized Patients" (revised 9/20/2022), was reviewed and required, "Prevention of falls is the responsibility of every staff member. Patients will be assessed for fall risk factors using a validated fall risk assessment tool... A patient identified at 'high risk' for falls using the fall risk tool will have fall prevention interventions added to the plan of care which may include: ...d. Bed or chair alarms..."

2. The Hospital's "Initiate Fall Precautions if Fall Risk Score >8 and/or Cognitive Deficit Present" Guideline (undated) was reviewed and included, "Precaution Guidelines for Fall Risk Score <8 (Green/Low Risk): ...Bed Alarm ... for Fall Risk Score >8 or <17 or with ANY Cognitive Deficit (Yellow/Moderate Risk): ... Chair Alarm ... for Fall Risk Score 17 or above (Red/High Risk): In addition to Green/Yellow Light Fall Precautions: Consider Safety Monitor (live sitter); Consider Floor Mats (if available); Bed Rails x3..."

3. On 10/12/2022, the Hospital's policy titled, "Observation and Monitoring of Patients Who May Require Additional Supervision" dated 08/2020 was reviewed and included, " ...The bedside RN [registered nurse] may request a patient safety attendant based on the need to manage behaviors and actual or potential safety concerns ...an order must be placed ...needing a patient safety attendant ...RN will orient the patient safety attendant to the patient ...Document safety Monitor in Use in EMR ..."

4. On 10/11/2022 at 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Intensive Care Unit on 08/21/2022 at 3:50 PM, with a diagnosis of traumatic rhabdomyolysis (breakdown of muscle tissue). Pt. #1's clinical record included the following:

- Pt. #1's Fall Risk Score was 20 (indicating high risk) on 9/18/2022 at 10:00 PM.

-The Registered Nurse (E #9) note dated 09/19/2022 at 4:08 AM included, "patient [Pt. #1] was sleeping and woke to use the bathroom, he states he forgot that 'he does not have legs," and fell landing on his L AKA [left above knee amputation] stump, opening his incision site. Bed alarm was activated, video monitor was in place, pt. [Pt. #1] room is directly across from nurses' station ...he states he did not hit his head ...."

- The patient safety attendant flowsheet note dated 09/18/2022 at 9:00 PM, by video monitoring included, " ... 09/18/2022 at 9:00 PM - pt. [Pt. #1] sleeping in bed ...10:00 PM - pt. in bed ...11:10 PM - pt. sleeping in bed ...09/19/2022 at 12:11 AM - pt. sleeping in bed ...1:10 AM - pt. sleeping in bed ...2:08 AM - pt. asleep in bed ...3:03 AM - pt. asleep in the bed ...3:30 AM - pt. [Pt. #1] getting back in bed staff in the room ..." In summary the video monitoring safety attendant note did not indicate patient trying to get out of bed and notifying/alerting the registered nurse (E #9).

- The physician's order dated 08/22/2022 at 12:54 AM included, "Patient safety attendant: Type - video...reason for patient safety attendant: Suicidal ... " Pt. #1's physicians' order were reviewed, the orders did not include that a patient safety attendant was requested for safety concern due to high risk for fall.

5. On 10/12/2022, the Occurrence ID #48963 dated 9/9/2022 at 3:30 AM, related to the Pt. #1's fall was reviewed and included, " ...Investigation Report: Learning from Defects Summary (LDS) - Fall with no injury, uncontrolled/witnessed (video monitor) -Failure Point: Non-compliance with call light notification for out of bed assistance ...Failure Point: Alert by video monitor - Unclear if video monitor staff set off the audible alert or notified staff through the phone ...was unsupervised out-of-bed activity identified as an appropriate time for video monitor staff to notify the nursing staff ...Failure Point: Use of urinal or bedside commode - Unclear if a urinal and/or bedside commode were available nearby the patient ..."



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6. The clinical records of Pts. #1, #2 and #10 were reviewed on 10/12/2022 and included the following:

- Pt. #1's fall risk assessment score was 15 on 10/11/2022 at 11:00 AM
- Pt. #2's fall risk assessment score was 17 (high risk) on 10/12/2022 at 5:02 AM.
- Pt. #10's fall risk assessment score was 22 (high risk) on 10/12/2022 at 8:00 AM.

7. An observational tour of the Medical 1 Unit was conducted on 10/11/2022, between 10:50 AM and 1:00 PM.

-At approximately 11:00 AM, Pt. #1 was observed sitting up on the medical bed; however, the bed exit alarm light was not on.

8. A second tour of the Medical 1 Unit was conducted on 10/12/2022, between approximately 11:20 AM and 12:00 PM. There were 2 patients (Pts. #2 and #10) on high fall risk precautions (red fall indicator noted outside of room door). Pt. 2 was lying in bed; however, the bed alarm was not on. Pt. #10 was sitting up in a chair, but a chair alarm pad was not set up.

9. On 10/12/2022 at 7:55 AM, the Registered Nurse (E #9) was interviewed. E #9 stated that on 09/19/2022 at approximately 3:30 AM, she heard the bed alarm go off for the patient (Pt. #1). E #9 stated that when she went to the room, she found the patient (Pt. #1) lying of the floor on his left stump. E #9 stated that she does not recall if the safety attendant notified her about the patient trying to move out of the bed.

10. On 10/12/2022 at 10:42 AM, the Chief Nurse Officer (E #10) was interviewed. E #10 stated that even if there are bedside sitter patients do fall, they could not have done anything differently to avoid (Pt. #1) from falling. E #10 stated that she was not sure if the video monitoring safety attendant notified the registered nurse of patient trying to move out of bed.

11. An interview was conducted with Staff Nurse (E#14) on 10/12/2022, at approximately 11:25 AM. E#14 stated that the chair Pt. #10 is sitting on does not have an alarm on it.

12. An interview was conducted with Clinical Educator (E#15) on 10/12/2022, at approximately 11:35 AM. E#15 stated, "We promote fall risk precautions for every patient" especially on a post-surgical floor. E#15 stated that bed alarms are turned on for every patient (regardless of risk level) whenever the patient is in the bed. E#15 stated that the alarms should only be off if the patient needs to get up or be transferred. E#15 stated that some chairs have built-in alarms and for chairs that don't have it built-in, we have alarm pads that can be placed under the patient when using any chair. E#15 stated that alarms system communicates with the call light system and will alert the nurses if the patient's weight is displaced outside of a designated zone. E#15 stated that even if visitors are present by the patient, fall precautions should still be in place because "we don't depend on the visitors to prevent falls."

13. An interview was conducted with Staff Nurse (E#16) on 10/12/2022, at approximately 11:45 AM. E#16 stated that bed alarms are on for every patient when they are in bed. E#16 went into Pt. #2's room and noted that the bed alarm was off. E#16 turned the alarm on and stated, "It should have been on." E#16 stated that Pt. #2 gets physical and occupational therapy throughout the day and stated, "They may have forgotten to turn it back on when bringing the patient back to bed."