HospitalInspections.org

Based on review of documentation and an interview with staff # 1, the facility failed to ensure that services were provided in a safe manner; patient # 1 was found on the floor.

Findings were:
Review of documentation safety action learning tool (SALT) completed by staff # 2 stated, " The event was preventable and resulted in injury. The bed alarm was not checked prior to patient #1 being found on the floor. The phlebotomist came to the nurse's station to report that the patient was found on the floor."
Review of nurse and physician progress note 01/16/12 stated patient # 1 fell.

In an in-person interview with the supervisor staff # 3, at the time of the incident, on the afternoon of 08/06/12 at the facility, it was confirmed that the patient care technician staff # 4, did not reset the bed alarm and patient # 1 was found on the floor by the phlebotomist.