HospitalInspections.org

Based on document review and staff interviews, the Critical Access Hospital (CAH) staff failed to conduct a proper assessment for safety prior to removing a patient's personal alarm, used for the patient's safety, for 1 of 6 closed records reviewed with patients requiring the use of a personal alarm (Patient #1).

CAH administrative staff reported a census of 7 current patients including 1 patient requiring the use of a personal alarm, during the onsite visit.

Failure to provide an adequate nursing assessment prior to discontinuing the use of a personal alarms resulted in Patient #1 exiting the bed without staff knowledge, by way of an alarm, and falling in their room.

Findings include:

CAH policy titled Fall assessment and fall risk protocol stated, in part. "...Risk of falls protocol: 3. alarm is on." The CAH did not have a policy specific to the use of personal alarms.

CAH policy titled Fall Prevention Policy dated 2/2012 directed staff to implement the following additional fall prevention interventions for patients determined to be at high risk for for falls or risk for injury from a fall, in part.
-Instruct family and patient on safety concerns and encourager their assistance and presence.
-Utilize personal alarm, bed alarm, and chair alarm.

Variance Report dated 9/15/14 at 6:00 AM revealed Patient #1's family member, resting at the patient ' s bedside, notified staff the patient was on the floor. The family member reported being asleep when the fall occurred and did not witness the fall. Staff found the patient under side of the bed laying on their right side; the patient had a gown and socks on. Patient #1 was responsive to staff and family. Patient remains confused stating he/she was at the farm. Patient easily but only briefly re-oriented to surroundings. Patient's pupils were sluggish to light but otherwise normal. Full range of motion to extremities with no bruising identified. Patient had redness to the right knee. Patient had small slit to lower lip with all teeth intact. Additional information showed staff had a discussion with family prior to discharge on 9/17 to hospice; a concern was expressed about the alarm not being in place at the time of the fall. Review of the patient's record does not document why the alarm was removed. Families concerns noted and will follow up with staff regarding fall prevention.

Review of Patient #1's medical record #92638548 revealed the patient was admitted to skilled nursing care on 9/1/14 for shortness of breath and congestive heart failure. Staff applied a personal alarm on 9/1/14 because the patient's fall risk assessment was high, 85, and the patient had some confusion. The patient had the alarm on until 9/14/14 at 7:40 PM when staff removed the alarm. The staff did not document an assessment or reason for removing the personal alarm in the medical record. At the time staff removed the personal alarm, the patient's fall risk assessment score was 75 meaning the patient was at high risk for falls. The staff documented on 9/15/14 at 6:19 AM the patient fell. See Variance Report dated 9/15/14.

During an interview on 10/28/14 at 10:30 AM, Staff C, Chief Nursing Executive stated fall prevention is part of annual education for all nursing staff. The CAH did not formally educated staff on the use of personal alarms though. Patient #1's fall on 9/15/14 was a concern because staff removed the personal alarm without a proper assessment for safety. Personal alarms were used for a reason and staff should not remove them just because a family member requests this.

During an interview on 10/27/14 at 2:00 PM, Staff A, Certified Nursing Assistant (CNA) stated when she arrived at work on 9/15/14, report revealed Patient #1 had fallen that morning. Staff A said when she entered the patient's room, the personal alarm was not on the patient, but a family member was in the room with the patient. Staff A said she placed the personal alarm on the patient and tested it showing proper functioning of the alarm. Staff A said she questioned Staff B, Registered Nurse, (RN) about why the personal alarm had been removed. Staff B stated she removed the alarm because a family member was in the room with the patient. Staff A did not recall any injuries to the patient from the fall.

During an interview on 10/28/14 at 9:05 AM, Staff B, RN stated on 9/14/14 Patient #1's fall risk assessment score was 75 at 7:59 PM. This showed the patient was a fall risk and the patient had a personal alarm for safety. Staff B said she removed the personal alarm because the family requested this so they could sit closer to the patient when visiting while the patient was in bed. Staff B said she routinely removed the personal alarms when families requested this during visits, but attached the alarms when the family members left the hospital. Patient #1 did not have the personal alarm on when falling out of bed on 9/15/14 at around 6:19 AM. The patient bit her lip, but had no other identified injuries during the post fall assessment.

During an interview on 10/28/14 at 8:15 AM, Practitioner A, Medical Doctor (MD) stated she was notified by staff about the fall of Patient #1 on 9/15/14. Practitioner A did not identify any injuries during her evaluation. Practitioner A said she discussed treatment options with the family and they decided to observe the patient for increased pain and follow up with testing if the patient's condition required the tests. The family decided to pursue hospice care at this time.