HospitalInspections.org

Based on review of facility policy and procedures, Patient Rights and Responsibilities, facility documents, the facility's Quality and Performance Improvement Plan, medical records (MR), and interviews with staff (EMP), it was determined the facility failed to provide safe transfer of the patient from the stretcher to the bed for one of ten medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9 and MR10).

Findings include:

Review of the facility policy and procedure "Safe Patient Transfers Dependent Patient," dated reviewed May 2011, revealed "Transfer from bed to stretcher ... 4. One staff member should be on the stretcher side of bed and another staff member should be on the opposite side of bed. ... 7. Once the patient is on the stretcher, raise and secure siderails and apply safety straps if present. Do not leave a confused or disoriented patient unattended on a stretcher."

Review of the facility policy and procedure "Fall Prevention," dated reviewed May 2011, revealed "... 6. Fall risk must be assessed upon admission, q [sic] shift, upon any change in condition (i.e. steady gait becomes unsteady, change in mental status or medical condition, addition or change in medications which affect fall risk or severity of injury, when a patient is transferred to another department, and after a fall). Fall prevention interventions should be re-evaluated and modified as patient condition changes. ..."

Review of the facility's "Rights and Responsibilities," dated reviewed October 2011, revealed "Care Delivery: You have the right to: Receive kind, respectful, safe quality care delivered by skilled staff."

Review of the facility document "Incident Report" for December 8, 2011, revealed the patient "was being transferred to the ICU (Intensive Care Unit) secondary to respiratory insufficiency from 2W on an inflated air mattress ... stretcher aligned next to bed and one side rail was down. Nurse in attendance turned [their] back away from patient. ... Transporter left side of stretcher to obtain an oxygen adapter and patient rolled off the left side and was found on floor, bleeding from left lateral side of head. Left siderail of stretcher was down. ... Brakes on both bed and stretcher were in the on position."

Review of the facility's "Quality and Performance Improvement Plan," dated revised October, 2011, revealed "... F. Event Response Team (Ad Hoc): The Event Response Team conducts analysis on any unexpected occurrence involving death or serious physical or psychological injury or any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. The focus of the team is to understand the causes that underlie that event, and on making changes in the organization's systems and processes to reduce the probability of such an event in the future."

Review of MR1 revealed that the patient had been admitted to the facility from a nursing care facility with a change in mental status. A few days later the patient was transferred to the ICU due to respiratory distress. The patient was transferred on an air mattress. The patient fell to the floor when the nurse turned their back from the patient. The siderail on the left side of the stretcher was dropped while the transporter left to retrieve an oxygen adapter. The patient sustained a subdural hematoma as a result of the fall.

Interview with EMP1 on December 14, 2011, at approximately 9:30 AM confirmed the stretcher siderail was dropped (down), the patient had been left unattended and fell to the floor, while on an inflated air mattress. EMP1 confirmed the patient sustained an injury to the head, resulting in a subdural hematoma. EMP1 confirmed the patient's condition deteriorated, and the patient later expired.

Interview with EMP2 on December 14, 2011, at approximately 10:00 AM confirmed they transferred the patient to the ICU due to the change in the patient's respiratory status. EMP2 confirmed EMP2 and the transporter took MR1 to the assigned bed in the unit and aligned the stretcher next to the bed. EMP2 confirmed they turned away from the patient to write in the patient's chart. EMP2 was not aware the transporter had lowered the siderail. EMP2 realized the patient had fallen from the inflated air mattress when they heard a loud noise. EMP2 confirmed the ICU staff were not present when they brought the patient to the room.

Interview with EMP3 on December 14, 2011, at approximately 10:30 AM revealed they accompanied the nurse in the transfer of MR1 to the ICU. In the process of retrieving an oxygen adapter, EMP3 confirmed they left the patient unattended for a few moments, and the patient fell from the stretcher.