HospitalInspections.org

Based on a review of medical records (MR), facility documentation, and interview with facility staff (EMP), it was determined that the facility failed to provide patients with care in a safe setting for three of 11 medical records (MR1, MR7, and M9).

Findings Include:

Review of "Patient Rights" policy and procedure dated January 2013, revealed, " ... Statement of Policy: It is the policy of Memorial Medical Center to respect the rights of patients during their hospitalization and to recognize that each patient is an individual with unique health care needs. Staff will provide considerate, respectful care, incorporating patient's personal values and belief systems and to strive to protect each patient's dignity. ... Requirements: Memorial Medical Center assures patient rights are supported by the following: ... 9. Recognition of the patient's right to formulate an advance directive and to appoint a surrogate to make health care decisions. ... 11. Providing a mechanism for receiving and responding to patient's and family's complaints or grievances concerning quality of care. ... . 12. Policies and processes to ensure a patient's right to management of symptoms related to their illness, including prompt and appropriate management of pain." Attachment to Policy included: "A Statement of the Patient's Rights Conemaugh Health System is committed to providing quality care to all patients and to make their visit as pleasant as possible. Our concern and respect for you, our patient, is addressed in this Statement of Patient's Rights." revealed, "1. You have the right to respectful care given by skilled staff. ... 8. In case of emergency, you can expect emergency treatment without delay. ... You have the right to be free from any form of restraints-both physical and drug-that is not medically necessary. ... 9. You have the right to quality care and high professional standards that are always kept and reviewed. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid any personal discomfort. ... ." (jb)
Review of policy and procedure entitled "Falls Reduction Policy-Inpatient," dated 6/26/13 revealed, "1. Statement of Policy, Patient safety is an ongoing responsibility of all staff. In order to reduce the risk of patient injuries as a result of a fall, the staff will assess and re-assess the patient's level of risk for fall. Based on the assessment, staff will initiate the appropriate layers of safety. II. Purpose: 1. Establish a consistent mechanism to identify patients who are at risk for a fall. 2. Identify patients, not initially deemed a fall risk, through daily reassessment. 3. Provide on-going assessment of all patients utilizing the "Daily Fall Risk Assessment." 4. Establish comprehensive standards of care for the initiation of appropriate safety measures and interventions ... IV. Procedure: 1. The nurse will screen every patient for fall risk potential upon admission by utilizing the "Daily Fall Risk Assessment" located in Care Manager ... 3. Fall Prevention Measures for all patient regardless of risk will be implemented (listed on Pg 3). 7. Patient beds MUST be in the lowest position. The 2 upper side rails are to be in the upright position. 8. Additional fall prevention measures will be implemented for the High Falls Risk patient: (includes yellow star, yellow arm band, yellow non skid slippers, hourly check ...V. Instructions for Completion of the Daily Falls Risk Assessment. 1. The RN will evaluate the patient by scoring each of the "At Risk" criteria the patient presents with. The total score of the assessment along with the RN's clinical judgement will dictate the patient's level of risk for fall. If the RN, based upon clinical judgement, chooses to deviate from the risk level determined by the fall risk assessment, he or she must document in the patient chart the reason that substantiates their decision. 2. The patient will be classified into 1 of 3 Fall Risk categories. (Scores on Falls Risk Assessment with Risk for Falls) 0-4 is Low (L), 5-8 is Moderate (M) and 9 or more is High (H) ... 4. The Falls Prevention Measures for patients at low, moderate, or high risk must be implemented. Clinical judgement, individual patient factors and family involvement do play a role in the selection of interventions. 5. Documentation. Falls Risk screen in Care Manager is to be completed on each reassessment. Screens: beds in lowest position, bed to 18" (lowest position for new hill rom versicare beds); low bed with landing strips on either side; Bed alarm on -- distinguish which of the 3 settings. ... VII. Fall Prevention Measures for the High Falls risk patient: 1. These additional Fall Prevention Measures will be initiated for all patients identified as high risk for falls immediately upon admission to the nursing unit. a. Place the "Falling Star" marker outside the patient rooms to identify the patient at risk for falls. b. Designate falling star on the Kardex. c. The nurse will attempt to place patients at high risk for falls in patient rooms that are easily observed. This may involve moving the patient to a room close to the nurses' station. d. Place a yellow arm band on patients at high risk of falls. e. Display a yellow falling star outside the patients rooms at high risk for falls. f. Place yellow non-skid slippers on patients at high risk for falls. g. Check the patient at a minimum of every hour and maintain close supervision ... EQUIPMENT: Yellow Slippers and Yellow arm bands are par stocked on each Nursing Unit. Yellow magnetic stars were delivered to each nursing department- the stars are to be reused- wipe with hydrogen peroxide wipes after each use. New stars can be acquired ... Summary: 1) Patients at high risk for fall requirements: Place a yellow ARM band & Yellow slippers on the patient ** When a patients fall risk status changes to a High falls risk - apply the yellow Fall risk arm band, yellow slippers, & star outside the patient's door immediately ... ."
Review of "One to one Observation 1:1- Conemaugh Health System-Memorial Medical Center Nursing Practice" policy and procedure dated October 2012, revealed, " ... Nursing Actions: ... B. Safety devices will be utilized: ... -Bed alarm is to be set on the Versa-care beds. Other alarm devices are to be used on patients who do not have a bed alarm built into their bed. ... ."

1) Review of "Falls Risk Assessment" documentation revealed that on May 13, 2013, at 1:00 AM the patient was confused and disoriented times two, had impaired judgement, unsteady gait, and limited activity tolerance. The "Falls Risk Score" was 20 with nine or higher indicating a high fall risk. Documentation revealed that the "Fall Star Bundle" was not implemented until May 16, 2013, at 7:45 AM.

Interview with EMP1 on July 12, 2013 at 9:30 AM revealed, " ... I don't think [the patient] had the yellow socks on. ... The son was asking me some questions that I couldn't answer, so I gave the phone to the nurse and the nurse did say that they forgot to set the alarm after [the patient] bath. ... ."

2) Following the open inpatient medical record review of MR3-MR12, on July 12 2013, EMP1 confirmed that there were no falling stars on the door frames for MR7 and MR9.