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Based on policy and procedure review, observations, medical record review, post-fall huddle review, incident report review and interviews, the nursing staff failed to supervise and evaluate the nursing care for each patient, by failing to ensure bed alarms were properly connected and activated for 1 of 3 patients reviewed with a fall (Pt #3).

Findings included:

Review on 06/02/2021 of the policy and procedure titled "Fall Prevention Program for Adults" effective date 11/2020 revealed "PURPOSE To provide a clear and uniform process for assessing adults and reducing falls and significant injuries related to falls. ... PROCEDURE: ... B. Interventions 1. Universal Interventions (Morse Fall Scale Score 0-49...) include: a. Offer/provide toileting during hourly rounds b. Offer/provide non-skid footwear c. Assess coordination and balance before assisting with mobility activities d. Maintain bed in a low and locked position e. Arrange call light and frequently used items (i.e., water pitcher, urinal, phone, TV remote) within reach of the patient f. Maintain a clutter free environment by performing environmental assessments of the patient's room g. Provide adequate lighting in room (including bathroom) h. Communicate any change in the patient's status with the physician. 2. High Risk Interventions (Morse Fall Risk Score 50 or above...) a. All Universal Interventions in place...g. Initiate a tab alarm whenever the patient is in the chair and activate bed alarm whenever the patient is in bed when clinically appropriate. Consider a tab or bed alarm for the following situations: 1. Patients who attempt to get out of bed unassisted when assistance is needed or overestimates their abilities ...Patients who seem to be at risk based on nursing judgment, i.e. age, eyesight, medications ... 4. The family will be notified as soon as possible after the fall, unless otherwise instructed by the patient."

Observation on 06/03/2021 at 1345 during a tour on the 3rd North Tower Unit identified a bed stored in a closed room that the bed alarm cable was bent, and staff were unable to connect to the wall bed alarm cable.

Observation on 06/03/2021 at 1345 on the 3rd North Tower Unit, during a staff demonstration of the bed alarm system, revealed when activated, the bed alarm sounded in the patient room, activated the alarm at the nurses' station console, and initiated a call to the primary nurse's phone, as well as, activated the three lights (white, blue and white) above the patient's room door when the bed alarm was turned on and the wall cables were connected properly to the bed cable. Observation revealed, during a staff demonstration of the bed alarm system where the bed alarm was turned on and the bed cable was not connected to the wall cable, the bed alarm sounded in the room, with no activation of the console at the nurses' station and no initiation of a call to the primary nurse's phone.

Review of the closed medical record for Patient #3 revealed an 87-year-old female that presented to the Emergency Department (ED) on 04/30/2021 at 2036 with a chief complaint of Altered Mental Status and was admitted to the hospital on 04/30/2021 at 2217. Review of the Morse Fall Risk Scores for Patient #3 revealed on 05/02/2021 at 1000 and 2016 the fall risk score was "50". Review of nursing note documented on 05/02/2021 at 2016 revealed bed alarm was turned on. Review of the post-fall huddle notes dated 05/02/2021 at 2045 revealed Patient #3 was high risk for falls and bed alarm was turned on, but staff had failed to connect the cable that activated the bed alarm to the nursing station console and the nurse's phone. Review of the post-fall nursing notes documented on 05/02/2021 at 2046 revealed Patient #3 was found by staff, on the floor, beside the bed, laying on her right side. Patient #3 complained of right hip pain after the fall. The nursing note revealed the Physician, family and nursing supervisor were notified. Physician orders were received for x-rays. The right hip and pelvis x-rays were completed on 05/02/2021 at 2059. An orthopaedic consult was ordered on 05/02/2021 at 2200 and completed on 2219. Patient #3 complained of right shoulder pain and a right shoulder and right femur x-ray were completed at 2215 on 05/02/2021.

Review of the incident report follow-up by the Nurse Manager on 05/03/2021 at 1717 revealed "Patient fell shortly after arriving to the room. Investigation shows that bed alarm was in place, (sic) but was not plugged into the wall so it did not function correctly." Incident Report revealed "The staff were coached and reeducated on the importance of checking the environment upon admission and during hourly rounding."

Interview on 06/02/2021 at 1420 with RN #1 (Registered Nurse) revealed she was the primary care nurse for Patient #3 on 05/02/2021. Interview revealed RN #1 was in a patient room across the hallway from Patient #3's room when she heard the bed alarm and ran across the hall to Patient #3's room. Interview revealed the bed alarm could be heard in Patient #3's room, however RN #1's phone was not activated due to the bed alarm cables were not connected to the in-wall board cables. Interview revealed RN #1 failed to recognize, during the patient and environment assessment that the cables for the bed alarm were not connected correctly.

Interview on 06/03/2021 at 1015 with RN #2 revealed RN #2 was notified by EVS (Environmental Services) staff that Patient #3 had fallen and was on the floor. RN #2 revealed she went into Patient #3's room and contacted additional staff for assistance. Interview revealed RN #2 did not recall if the bed alarm sounded in Patient #3's room after the fall.

NC00176895