HospitalInspections.org

Based on observations, staff interviews, and document review it was determined that the facility failed to provide care in a safe setting with potential for harm to all patients in the ICU (14 beds). Findings include:

Facility policy titled "Provision of Patient Care Plan" stated, " ...Departments and patient care units are equipped to meet the needs of patients ...Beebe Healthcare Board of Directors is responsible for the quality and safety of services provided. The Quality and Safety Committee of the Board, in partnership with the Medical Staff is responsible for the monitoring and oversight of care and services provided through its Quality and Safety Program ..."

Facility policy titled "Fall Prevention and Management" stated, " ...Beebe Healthcare should create a safe physical environment for our community and healthcare patients, both inpatient and outpatient. When identified as a risk for falls, fall interventions appropriate to the care setting should be implemented to reduce the incidence of falls and to reduce the risk of harm resulting from falls ...Beds equipped with safety features (top side rails, low position and bed alarm) should be engaged for patients according to their fall risk score ..." Appendix A of the Fall Prevention and Management Policy, titled "Clinical Staff: Guidelines for Fall Prevention Interventions" outlines that interventions for patients with a High Risk for Fall [Morse Fall Assessment score of >45] include utilization of bed/personal alarms.

Facility policy titled "Close Observation" stated, " ...This policy applies to all patients requiring evaluation and need for Close Observation to prevent potential harm ...Close Observation can be achieved by qualified personnel or Tele-sitter monitoring ...It is the policy of Beebe Healthcare that patient monitoring is instituted to maintain the safety of each patient and provide a system of intensity of patient observation and oversight ..."


On 10/10/23 Patient 1 was admitted for a heart attack and had a stent successfully placed. The patient was held for monitoring and given anticoagulants. On the night of 10/11/23 the patient was found on the ground at approximately 10:30 PM. A CT scan showed a brain bleed. The patient later died on 10/12/23 at 9:24 AM.

A Serious Safety Event meeting took place with facility leadership at 8:00 AM on 10/12/23. It was determined that a RCA (root cause analysis) would be conducted to investigate this event.

The hospital was able to quickly identify that the bed alarm was not on at the time of the fall, despite the medical record showing this intervention was in place. A potential contributing factor was identified, as the beds lack a visual indicator identifying the activation of the bed alarm.

Fall re-education was implemented during semi-annual staff education occurring between 10/16/23 - 10/30/23.

In an interview on 10/31/23 at 1:28 PM, Employee 6, Director of the ICU, reported the hospital took initial actions to protect patient safety during the interim while the RCA process was being completed. These initiatives included charge nurses monitoring that bed alarms are engaged for all patients, documenting bed alarm checks on a safety checklist, ensuring that bedside nurses are doing bedside report and safety handoffs to include assuring bed alarm engagement, and the Hill-Rom smart client (an app that can be accessed on the computer desktop that can let you know what alarms are activated on the bed) was made available on all computers on the unit.

A unit tour was conducted on the ICU at that time (10/31/23 at 1:28 PM) to review the charge nurse safety checklists and to review the Hill-Rom smart client application. There was no evidence of a charge nurse safety checklist on the unit.
Employee 14 was the charge nurse on the unit at that time and reported that he/she did not have access to the Hill-Rom app. The employee indicated that the unit manager and educator help to monitor the application. Employee 14 reported checking the patient bed alarms personally an estimated 6 times per shift in addition to checking patient bed alarms during charge nurse report at the beginning and end of each shift. The employee indicated that there were no monitoring tools in place to document these checks.

Employee 13, the ICU nurse educator, reported that charge nurse audits are done informally twice per shift. Charge nurses have the responsibility of ensuring bed alarms are activated for all patients. Employee 13 was monitoring the application and stated that if there was an alarm that was off, it would be the responsibility of the nurse to go check and see why the alarm was not on. The employee was unable to identify why 2 out of 4 bed alarms were shown as being off on the application. The employee was unsure if the application was showing one bed alarm as off because it was on a less sensitive setting. Additionally, there were 4 beds that were not showing up on the application. The employee indicated that one had just returned to the unit and the other 3 beds were assigned to another unit. The employee did not take action to check the beds with alarms that were showing as off or disconnected, did not ask another staff member to check for them, and did not indicate that they were going to contact the other unit about the beds that were disconnected.

The ICU Director, Chief Nursing Officer, and Director of Risk were notified on 11/1/23 at 1:00 PM that there was no monitoring tool in place, all staff members did not have access to the Hill-Rom app, and staff were unable to describe how the application worked. The Director of the ICU indicated that formal monitoring would be implemented by 4:00 PM on 11/1/23. Surveyors were provided an ICU CNA/PCT Rounding Tool at the end of the day on 11/1/23 that included bed alarms to be verified 2 times per day and included a reminder to check bed alarms during hourly rounds.

On 11/2/23, a tour of the ICU was conducted at 1:34 PM. Employee 17, charge nurse, was unsure of the status of three patients whose beds were not communicating with the application. Employee 17 indicated that one was assigned to another unit and if there were questions about beds assigned to another unit, the nurse would go "help out". Employee 17 stated that they had not done so at the time of the interview. When asked about any fall monitoring tools, a Fall Audit Bundle form was produced that had been filled out by night shift on 11/1/23. Employee 17 verified that the form is to be filled out once a shift and that there were no other monitoring tools for falls in use. Employee 17 stated that he/she had been a charge nurse for a number of years and that he/she has had access to the Hill-Rom app since becoming a charge nurse. The employe indicated that it had recently become a practice in the last couple of months to monitor the app regularly and states he/she tries to check it at least hourly.

In an interview after the tour of the ICU on 11/2/23, Employee 5 indicated that there is nowhere in the RCA process to identify and implement immediate actions. He/she also shared that education is planned for nurses hospital-wide on 11/6/23 - 11/17/23, focusing on how to use the Hill-Rom application and reeducation on restraints. Confirmed that as of 3:03 PM on 11/2/23 it was uncertain how long the beds had not been communicating with the application.

An email provided on 10 /31/23 included evidence that a problem with connectivity was identified on 10/24/23 for bed 246, and a request was placed to informatics to address. An email reply indicated that the problem was not solved and two other beds, 249 and 253, also had connectivity problems. Bed 253 reportedly spontaneously resolved. The issue was forwarded to the vendor and an email reply indicated a technician would come on 10/26/23 to address. As of 11/2/23, beds 246 and 249 continued to lack connectivity.

Employee 5 confirmed on 11/2/23 at 3:03 PM that no plan had been initiated to ensure the safety of patients whose beds were not connecting to the application.



Initial actions identified to protect patient safety and ensure that bed alarms were appropriately utilized included use of a computer application to visually indicate if the beds were activated for all patients and charge nurse monitoring that bed alarms were on for all patients twice a shift.

On tours of the unit on 10/31/23 and 11/2/23 it was revealed that not all staff had access to the computer application, did not have adequate training on how to utilize the application, not all beds connected to the application, no interventions had been instituted for those patients in beds without connectivity, and there was no documentation of charge nurse monitoring.

Staff education, installation of the computer application, telemonitoring of patients in beds without connectivity, and a charge nurse monitoring tool were initiated prior to the survey exit.

Based on record review, document review, and staff interviews it was determined that the facility failed to use restraints in accordance with a provider order for 2 out of 3 patients in the sample that had restraints (Patient #s 1 and 3). Findings include:

Facility policy titled "Restraint Use" stated, "...The initial order should be placed prior to applying restraints (except for emergency situations) and renewed by the provider every 24 hours ..."

A) Patient #1
A Patient Expiration Record was documented on 10/12/23 at 9:39 AM by Employee 17. That document indicated that the patient had been in restraints in the 24 hours prior to expiring.

During an interview on 11/1/23 at 3:18 PM with Employee 17, they stated that when they came on for their shift at 7:00 AM on 10/12/23, they removed the soft wrist restraints from the patient with the nurse that was leaving from the previous shift. Employee 17 indicated that they were placed on the patient post-fall, when the patient was intubated, after returning from CT Scan at 12:28 AM on 10/12/23. Employee 17 verified that there was no obvious evidence of injury related to the soft wrist restraints.

Review of the medical record showed no evidence of a provider order for restraints.

Employee 17 confirmed that there was no provider order for the use of restraints on 11/1/2023 at 3:18 PM.

B) Patient #3
Review of the medical record showed the initiation of restraints for the patient on 10/28/2023 at 10:00 PM and continued use until being discontinued on 11/1/23 at 4:13 PM.
There was no evidence of daily renewal orders for restraints on 10/30/23 or 10/31/23.

The finding above was confirmed by Employee 12 on 11/3/23 at 11:30 AM.

Based on observation, document review, and staff interview it was determined that the facility failed to secure all medications for 1 out of 12 patients admitted to the ICU (Patient # 8). Findings include:

Facility policy titled "Drug Storage and Inventory Control" stated, "...To ensure that medications will be stored to maintain integrity...Medications and drugs are stored in locked areas not accessible to unauthorized persons..."

During a tour of the ICU on 11/1/2023 the following was discoved:
-an unopened syringe and a vial of medication was seen on top of the computer on wheels.
-there was no nurse in the room (242) at the time of discovery.
-there were two family members in the room with the patient at the time of discovery.

Staff interview with Employee #6 on 11/1/2023 at 11:30 A.M revealed the following:
-when shown the medication and unopened syringe, Employee #6 stated "they should be locked in the drawers" and confirmed the finding at that time.

Based on observation, facility policy review, and staff interview the facility failed to follow its infection prevention and control program policies and procedures, with potential negative impact for all patients in the ICU (14 beds), Findings include:

I. The hospital policy titled "Hand Hygiene Practices for the Prevention of Infection" stated, "...Decontaminate hands before having direct contact with patients...Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient...Decontaminate hands after removing gloves...Patients in isolation...wash hands prior to entry into patient's room..."

On 11/2/2023 at 11:40 AM, the following was observed in the Emergency Department during medication administration as registered nurse (RN) Employee #23:

-washed hands
-held gloves in his hand
-accessed medication workstation on wheels to remove medication
-picked up patient's wrist failing to sanitize hands and don gloves
-scanned patient wrist band
-placed medication in a medication cup
-took empty blister pack to trash can pushing a workstation on wheels out of the
way
-put blister pack in trash
-touched patient's armband and wrist
-went to medication workstation on wheels
-donned gloves without sanitizing hands after coming in contact with inanimate
Objects and the patient
-gave medication to patient

Employee #23 RN failed to sanitize his hands after touching inanimate objects, before donning gloves, and before touching patient.

These findings were confirmed by Employee #23 on 11/2/2023 at 11:44 A.M.


II. The hospital policy titled "Infection Prevention Guidelines for Environmental Services" stated, "To reduce the risk of healthcare associated infections that may occur as the result of exposure to contaminated surfaces...maintain a thoroughly clean environment throughout the hospital by reducing the pathogens ...".

The hospital policy titled "Cleaning of Equipment" stated, "...Cleaning and disinfecting high-touch areas play a major role in providing a clean, safe, sanitary environment for patients, visitors, and staff...".

Hospital staff accompanied the surveyor during flash tour of the hospital ICU. The following was observed and confirmed at the time of discovery:

Hospital ICU Nutrition area on 11/1/2023 at 11:10 A.M.
- White residue on the counter between the ice machine and the sink.
- White residue in the bottom of the sink.
- Brown residue on the right side of sink.


These findings were confirmed at the time of observation by Employee #6 ICU Director.