HospitalInspections.org

Based on policy review, medical record review, and interview, the hospital failed to ensure an incident event report was completed when a cardiac heart monitor fell on Patient #1's foot causing swelling and pain.

Findings include:

Review of the policy "Corporate Event Reporting," dated 01/22/25, revealed when an event occurs that resulted or could have resulted in an unintended adverse development in a patient's condition, whether an inpatient or outpatient, the web-based event reporting system (STARS) must be accessed and a report entered. If a medical device caused or contributed to this, staff are to complete a "STARS" report.

Review of the medical record for Patient #1 revealed on 06/23/25 at 04:05 PM, Patient #1 presented to the hospital. On 06/23/25 at 04:35 PM, Staff (Q), Physician, ordered constant cardiac monitoring by telemetry (continuous tracking of heartbeat using electrodes and monitor). At 10:59 PM, the registered nurse notified Staff (L), Physician Assistant that a heart monitor dropped on Patient #1's foot a few days prior. The left foot assessment by Staff (L) noted increased left foot swelling, redness, and pain with palpation. An x-ray was ordered.

Interview on 08/14/25 at 03:30 PM with Staff (C), Hospital Administrator, revealed no incident event report was completed for Patient #1.