HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of two patients. Based on medical record review, staff interview and policy review the CAH failed to conduct preventative maintenance for one of two patient bed alarms.

Findings include:

- The CAH's policy "Lockout/Tagout Policy" reviewed on 3/14/12 at 3:14pm directed "...When an employee finds that a piece of equipment is not working properly or deems it unsafe to operate, it is to be reported to the supervisor or department manager immediately. The manager will " Tag out " the equipment by placing a "Do Not Use" tag on the equipment and send a requisition for repair to the maintenance department...Do not attempt to repair the equipment yourself ..."

- Patient #1's medical record review on 3/12/12 at 3:15pm revealed an admission on 1/26/12 with a diagnosis of Pneumonia. Patient #1's medical record indicated the patient fell on 1/28/12 at 6:35am and sustained a fracture of the right hip.

Patient #1's history and physical indicated the patient was alert and confused. The admission nursing history classified them as a fall risk, had a fall risk wristband on, alert to person, confused, and gait unsteady. The medical record contained a nursing care plan for fall risk due to unsteady gait, weakness, confusion, and history of falls.

Staff E, documented in the nurses notes on 1/28/12 at 6:35am that patient #1 attempted to get out of bed on their own and found lying on the floor. Staff E's documentation indicated the bed alarm did not sound to alert nursing staff of patient #1 being up and out of bed.

Staff C documented in the nurses notes on 1/27/12 at 2:00am "...Pt (patient) up to ambulate without assist multiple times, bed alarm to alarm, at times but not with every attempt to ambulate...Bed alarm remains on ..."

Staff C interviewed by phone call on 3/14/12 at 6:05pm, acknowledged patient #1's bed alarm on 1/27/12 failed to sound each time they got out of bed. Staff C thought they had fixed the bed alarm so it would sound when the patient attempted to exit the bed.

Staff C failed to follow the CAH's policy to remove faulty equipment from use and provide for the safety of a patient at risk for falls.

The Critical Access Hospital (CAH) reported a census of two patients. Based on medical record review, staff interview, and policy review the CAH failed to adequately train and supervise personnel to follow policies to protect the safety for one of seven sampled fall risk patients (patient #1).

Findings include:

- The CAH's job description "Acute Care Registered Nurse" reviewed on 3/15/12 at 8:00am directed "...checks for safe and efficient use of supplies and equipment...Knows policies and procedure of the hospital and the nursing department, Follows policies and procedures..."

- The CAH's policy "Lockout/Tagout Policy" reviewed on 3/14/12 at 3:14pm directed "...When an employee finds that a piece of equipment is not working properly or deems it unsafe to operate, it is to be reported to the supervisor or department manager immediately. The manager will "Tag out" the equipment by placing a "Do Not Use" tag on the equipment and send a requisition for repair to the maintenance department...Do not attempt to repair the equipment yourself..."

- Patient #1 ' s medical record review on 3/12/12 at 3:15pm revealed an admission on 1/26/12 with a diagnosis of Pneumonia. Patient #1 ' s medical record indicated the patient fell on 1/28/12 at 6:35am and sustained a fracture of the right hip.

Patient #1's history and physical indicated the patient was alert and confused. The admission nursing history classified them as a fall risk, had a fall risk wristband on, alert to person, confused, and gait unsteady. The medical record contained a nursing care plan for fall risk due to unsteady gait, weakness, confusion, and history of falls.

Staff E, documented in the nurses notes on 1/28/12 at 6:35am that patient #1 attempted to get out of bed on their own and found lying on the floor. Staff E's documentation indicated the bed alarm did not sound to alert nursing staff of patient #1 being up and out of bed.

Staff C documented in the nurses notes on 1/27/12 at 2:00am "...Pt (patient) up to ambulate without assist multiple times, bed alarm to alarm at times but not with every attempt to ambulate...Bed alarm remains on..."

Staff C interviewed by phone call on 3/14/12 at 6:05pm, acknowledged patient #1's bed alarm on 1/27/12 failed to sound each time they got out of bed. Staff C acknowledged they thought they had fixed the bed alarm so it would sound when the patient attempted to exit the bed.

The CAH failed to adequately train and supervise personnel to follow policies to protect the safety for patient #1 identified as a fall risk.

The Critical Access Hospital (CAH) reported a census of two patients. Based on medical record review, staff interview, and policy review the CAH failed to supervise, monitor, and protect the safety for one of seven sampled fall risk patients (patient #1).

Findings include:

- The CAH's job description "Chief Nursing Officer" reviewed on 3/15/12 at 8:00am directed "...Plan, develop, organize, implement, evaluate, and direct the nursing service area of the hospital...develop and implement procedures for the safe operation of all nursing service equipment...Ensure that all personnel operate the department's equipment in a safe manner..."

- The CAH's job description "Acute Care Registered Nurse" reviewed on 3/15/12 at 8:00am directed "...Supervise and assists personnel...provide skilled, professional nursing care to patients throughout the age continuum...checks for safe and efficient use of supplies and equipment..."

- The CAH's policy "Lockout/Tagout Policy" reviewed on 3/14/12 at 3:14pm directed "...When an employee finds that a piece of equipment is not working properly or deems it unsafe to operate, it is to be reported to the supervisor or department manager immediately. The manager will "Tag out" the equipment by placing a "Do Not Use" tag on the equipment and send a requisition for repair to the maintenance department ...Do not attempt to repair the equipment yourself..."

- Patient #1's medical record review on 3/12/12 at 3:15pm revealed an admission on 1/26/12 with a diagnosis of Pneumonia. Patient #1's medical record indicated the patient fell on 1/28/12 at 6:35am and sustained a fracture of the right hip.

Patient #1's history and physical indicated the patient was alert and confused. The admission nursing history classified them as a fall risk, had a fall risk wristband on, alert to person, confused, and gait unsteady. The medical record contained a nursing care plan for fall risk due to unsteady gait, weakness, confusion, and history of falls.

Staff E, documented in the nurses notes on 1/28/12 at 6:35am that patient #1 attempted to get out of bed on their own and found lying on the floor. Staff E's documentation indicated the bed alarm did not sound to alert nursing staff of patient #1 being up and out of bed.

Staff C documented in the nurses notes on 1/27/12 at 2:00am "...Pt (patient) up to ambulate without assist multiple times, bed alarm to alarm at times but not with every attempt to ambulate...Bed alarm remains on..."

Staff C interviewed by phone call on 3/14/12 at 6:05pm, acknowledged patient #1's bed alarm on 1/27/12 failed to sound each time they got out of bed. Staff C acknowledged they thought they had fixed the bed alarm so it would sound when the patient attempted they thought they had fixed the bed alarm so it would sound when the patient attempted to exit the bed.

- Administrative staff A interviewed on 3/14/12 at 4:30pm reviewed the documentation in patient #1's medical record by staff C on 1/27/12 and acknowledged the nurse's note indicated patient #1's bed alarm failed to sound each time the patient exited the bed. Staff A indicated they had recently conducted training for staff on guidelines for removing equipment that is not working properly. Staff A indicated staff C failed to informed them of the bed alarm not working properly on 1/27/12.

The CAH nursing staff failed to supervise, monitor, and protect the safety for patient #1.