HospitalInspections.org

Based on observation, staff interview and clinical record review, the facility staff failed to implement the fall plan of care for 2 of 10 sampled patients (Patient # 7 and # 10).

The findings include:

1) Review of the clinical record for Patient # 7 disclosed that the patient was admitted to the facility on 05/06/16 with a diagnosis which included Acute Cerebrovascular Hemorrhagic Stroke. An initial nursing assessment was completed on 05/06/16 and the patient was identified as high risk for falls. The plan of care identified issues for falls and assistance with activity of daily living as concerns for the patient. The interventions for the plan of care included assist with activities of daily living, toileting program, bed and chair alarm and transfer/ambulate with assistance at all times.

An observation of the patient was conducted on 05/20/16 at 12:30 PM. The patient was out of bed in his wheelchair. There was no chair alarm observed on the patient's wheelchair at this time. There was a noted alarm pad resting on the patient's bed.

An interview was conducted with the Rehab Clinical Manager on 05/20/16 at 12:35 PM who confirmed the patient did not have the chair alarm on his wheelchair. She further noted that the alarm was lying on the patient's bed.

An interview was conducted with the Physical Therapist at 12:40 AM who reports that the patient just had therapy and was returned to his room.

An interview with the Occupational Therapist was conducted on 05/20/16 at 12:55 PM. The therapist stated that the patient is to have his call bell within reach and is to have the alarm on his chair when he is out of bed. She further stated that she worked with the patient from 10:00 AM to 11:00 AM on 05/20/16. The patient was already out of bed in the wheelchair when she got the patient for occupational therapy. The patient had physical therapy prior to the OT. She confirmed the patient did not have the chair alarm on his wheelchair when she worked with the patient in therapy. She stated she also observed the patient in his room at approximately 12:00 PM. She said she saw the patient scooting around in his wheelchair, headed toward the bathroom in his room. She stated she assisted the patient to transfer to the toilet. She stated that patient did not have the chair alarm on that time either.

2) Review of the clinical record for Patient # 10 disclosed that the patient was admitted to the facility on 05/10/16 with diagnosis of Odontoid fracture. The initial nursing assessment was completed on 05/10/16 and the nurse determined that the patient was a high risk for falls. The patient is alert and oriented in all spheres. The plan of care identified issues of falls as a concern for the patient. The interventions identified on this plan of care included the following falling precautions: Call bell within reach; bed alarm; signage and nonskid socks.

The facility's administrative records identified that the patient sustained a fall on 05/12/16 at 3:50 AM. Review of the post fall assessment of the 05/12/16 fall noted that the patient did not have an alarm in place at the time of the fall. The post fall investigation/debriefing documenting that "the bed alarm was not indicated for this patient."

An interview with the Trauma Clinical Coordinator was conducted on 05/20/16 at 11:40 AM. The CC confirmed that the nurse documented on the post fall assessment that the bed alarm was not indicated for this patient but the plan of care documented that the patient was to have the bed alarm. She also confirmed the patient did not have the bed alarm in place at the time of the patient's fall.