HospitalInspections.org

Based upon record review, interview and policy review, the facility failed to assure safe in-house transfer and communication for continued care for one patient (#5) of three patients reviewed for in-house transfer. The facility census was 216.
Findings included:
1. Review of the policy, " Care Practice Guideline, Safety " for Fall precautions, showed the " Required Fall Risk Bundle " to include:
-Additional patient / family education
-Fall armband / signage
-Routine comfort rounding
-Yellow non-skid socks
-Supervised toileting
" As appropriate " to include:
-low bed with floor mat
-Bed and / or chair alarm
-PT /OT referral (Physical Therapy or Occupational Therapy)
-Place patient in a room close to nursing area " .

2. Record review for Patient #5, admitted 11/28-12/15/10 showed the patient fell at 4:00 AM, on 12/01/10, while on the Oncology Unit. X-Ray reports of 12/01/10, confirmed the presence of a fractured left humerus and hip.
3. During an interview on 1/04/11 at 2:01 PM, with Registered Nurse (RN), Staff I, showed he/she was caring for Patient #5 prior to his/her transfer to the Oncology Unit on 11/29/10. Staff I, stated that he/she had " told the receiving nurse about the chair / bed alarm. The tech (nursing assistant) was the one who took her. We do not have enough room on the S-BAR (transfer summary form). " Staff I stated that because of the Fall Protocol, the " Fall Risk Bundle " would require a chair / bed alarm. Staff I stated that the family had requested the use of a bed and chair alarm because the patient would become forgetful and / or confused during the night hours and might try to get up out of bed unassisted, and this might lead to a fall.
4. During an interview on 1/05/11 at 9:20 AM, with Staff J, showed he/she was caring for Patient #5 after his/her transfer to the Oncology Unit on 11/29/10. Staff J, stated that he/she had been told in report that Patient #5 was a fall risk because of his/her age, medications, and forgetfulness. The patient was able to use the call light, even though, he/she did not use it when needed. Staff J stated that he/she was not told in report that the patient needed the bed alarm and did not know if the patient had been using one prior to the transfer. Staff J stated that the use of a bed alarm is a judgment call for the nurse caring for the patient. When received to the Oncology Unit, the staff did not use the bed alarm for Patient #5.

Based on observation and interview, the facility failed to ensure patient privacy by placing patient's full names on patient charts, and by placing patient's last names on dry white erase boards in public view. The facility census was 216 at the time of the survey.
Findings included:
1. Observation of the general medicine floor (4000 Unit) on 01/03/11 at 2:00 PM, showed all patient charts with first and last names written on the spine. The chart rack was positioned in an area of the nursing station which was visible to anyone in the public hallway. This observation was witnessed and confirmed by Staff K, Registered Nurse (RN) Manager of 4000 unit. The census was 37 patients.

2. Observation of the Spine Center (5100 Unit) on 01/04/11 at 9:45 AM, showed all patient charts with first and last names written on the spine. The chart rack was positioned in an area of the nursing station which was visible to anyone in the public hallway. A white dry erase type board located in the nursing station with the patient's last name was visible to anyone in the public hallway. This observation was witnessed and confirmed by Staff L, (RN) Manager of 5100 unit. The census was 15 patients.

3. Observation of the Rehabilitation Unit on 01/04/11 at 10:40 AM, showed all patient charts with first and last names written on the spines. The chart rack was positioned in an area of the nursing station which was visible to anyone in the public hallway. This was witnessed and confirmed by Staff M, Director of Patient Care Administration. The census on the Rehabilitation unit was eight patients.

4. Observation of the Intensive Care Nursery Unit on 01/04/11 at 3:00 PM, showed all patient charts with last names written on the spine. The chart rack was positioned in an area of the nursing station which was visible to anyone in the vicinity of Room 1. This area has a capacity of eight patients. This was confirmed by Staff N, (RN) Outcomes Coordinator.

5. Observation of the Emergency Department (ED) on 01/05/11 at 10:20 AM, showed a white dry erase type board with patient's first and last name, and the tests that were scheduled for that patient in at area of the nursing station which was visible to anyone in the public hallway. This was also visible in the triage area of the ED. This was confirmed by Staff O, ED manager. The census in the ED was eight patients.