HospitalInspections.org

Based on a review of medical records (MR) and facility documents, and staff interviews (EMP), it was determined that the facility failed to ensure patients have the right to receive care in a safe setting for one of one medical record reviewed (MR1).

Findings include:

1) Review of facility policy "Patients' Notice and Bill of Rights and Responsibilities" dated December 1, 2014, revealed, " ... You have a right to: 1. Receive respectful care given by competent personnel in a setting that: a. is safe and promotes your dignity, positive self-image and comfort. ..."

2) Review of facility policy "Patient Falls-Assessment Re-Assessment and Documentation" dated May 30, 2014, revealed, "... It is the policy of UPMC to make reasonable efforts to identify patients who are at risk to fall so that appropriate preventative measures can be implemented to minimize the risk of harm from a patient fall and/or injury. ... Level 2 ... High Risk for harm: Recommended. All Universal Fall Interventions..Level 1 all recommended interventions..Bathroom Supervision..Bed Alarm."

3) Review of MR1's Post Fall/Harm Notification, revealed, " March 5, 2015 at 4:10 PM call bell ringing, bed alarm turned off, patient reports getting out of bed to get urinal, urinal on sink edge not within reach."

4) Review of MR1's Physician Order, dated February 28, 2015, revealed, "Alarm - Bed Check."

5) Review of MR1's Interdisciplinary Plan of Care, dated March 5, 2015, revealed, "Patient Safety Interventions: Assist with ADLs as needed, Implement Level 2 interventions for fall/harm, increased observation, Patient/Caregiver education, re-direction."

6) Interview with EMP3 on April 24, 2015, at approximately 10:30 AM, revealed, "When we reviewed the fall we determined the therapist did not turn on the bed alarm when they put [patient] in bed."