HospitalInspections.org

Based on document review and interview, the facility failed to provide a safe environment for 1 of 15 patients (Patient 2) medical records reviewed.

Findings Include:

1. Review of policy titled: Patient Rights and Responsibilities last revised 06/2018, indicated under number 28. "Humane care and protection from harm".

2. Review of Fall Prevention Algorithm indicated that patients with a Morse Fall Score of 45 or greater will be considered a high fall risk. That includes use of red socks and arm bands, physical therapy, education, manage medications and to utilize alarms.

3. Review of Patient 2's medical record indicated nursing documentation on the Morse Fall Scale indicated a risk score of 45 which is high risk. Physician orders on 08/07/19 at 5:00 pm indicated "Fall Precautions". Review of Patient Safety Observation Rounds dated 08/07/19 through 08/13/19 lacked documentation that bed alarms were used.

4. The Daily Nursing Narrative dated 08/14/19 indicated on 08/13/19 at approximately 8:00 pm the patient climbed out of bed and was found in doorway of room face down on the floor; bleeding from upper lip; front teeth "appeared to be stuck in patient's upper lip".
The medical record lacked documentation of use of bed alarm.

5. Interview: Interview on 08/28/19 at 4:00 pm with P54, Vice-President Clinical and Regulatory Compliance confirmed need for bed alarms and lack of use of bed alarms for Patient 2.