HospitalInspections.org

Based on facility policy and procedure review, observation during tours, and staff interviews, the facility failed to ensure bed and/or chair alarms were in use for patients identified for High Falls Risk in 9 of 12 patients. (21, 23, 24, 25, 26, 28, 29, 20, and 19)

The findings include:

Review on 04/10/2019 of the hospital policy titled, "Fall Assessment, Prevention and Management - Adult inpatients" revised on 12/15/2019 revealed, "... V. Procedure A. ... 5. Patient risk may NOT be lower than the calculated Morse fall scale score. Patient may be identified at high risk for falls regardless of the Morse fall scale score as indicated based on clinicians' assessment. ... Addendum B Adult Inpatient Falls Prevention Care Plan Interventions Morse Fall Scale Risk Level Guide - Risk Level Low/Moderate - Score 0-44 - Implement Low/Moderate Risk Fall Prevention Interventions. High Risk Score 45 and higher - Implement High Risk Fall Prevention Interventions ... High Fall Risk: Patients prevention interventions include: ` ... 8. Bed/chair alarms on at ALL times unless accompanied by a staff member ..."

1. Review of the medical record for Patient #21 on 04/11/2019 revealed a 52 year old female admitted on 04/05/2019 at 2034 with diagnosis of bilateral pulmonary emboli. Review of the "Mobility" flowsheet revealed Patient #21 had a Morse Fall Risk (fall risk assessment) score of 55 (high risk) on 04/05/2019 at 2056. Review of the "Fall Interventions/Purposeful Rounding" flowsheet revealed on 04/05/2019 at 2056 Patient #21 was High risk for falls with "10. Bed/chair alarms on at all times unless accompanied by a staff member" documented as an intervention. Review of the medical record revealed Patient #21 was identified as high falls risk throughout the hospitalization.

Observation on 04/11/2019 at 1458 during tour revealed Patient #21 was lying in bed with a sign above the bed on the back wall that read "Fall Alarms On at All Times." Observation revealed the bed alarm was off and there was no staff in the room.

Interview on 04/11/2019 at 1508 with RN #4 revealed she was the primary nurse for Patient #21. Interview revealed RN #1 was aware Patient #21 was a high falls risk and aware of the signage above the head of the bed. Interview revealed RN #1 thought she had turned the bed alarm on. Interview revealed the bed alarm was not on for Patient #21.

Interview with the Nurse Manager on 04/11/2019 at 1532 revealed "based on our sign and the policy, bed alarms should be on."

2. Review of the medical record for Patient #23 on 04/11/2019 revealed a 62 year old female admitted on 04/07/2019 at 1222 with a diagnosis of CAP (community acquired pneumonia). Review revealed Patient #23 received chemotherapy (type of cancer treatment) on 04/04/2019. Review of the "Mobility" flowsheet dated 04/07/2019 at 1222 revealed Patient #23 had a Morse Fall Risk score of 35 (low/mod risk). Review of the "Mobility" flowsheet dated 04/11/2019 at 0714 revealed Patient #23 had a Morse Fall Risk score of 60 (high risk). Review of the "Fall Interventions/Purposeful Rounding" flowsheet revealed on 04/07/2019 at 2018 Patient #23 was High risk for falls with "10. Bed/chair alarms on at all times unless accompanied by a staff member" documented as an intervention. Review of the medical record revealed Patient #23 was identified as high falls risk throughout the hospitalization.

Observation on 04/11/2019 at 1458 during tour revealed Patient #23 lying in bed. Observation revealed the bed alarm was off and there was no staff in the room.

Interview with the Nurse Manager on 04/11/2019 at 1532 revealed "based on our policy, bed alarms should be on."

3. Review of the medical record for Patient #24 on 04/11/2019 revealed an 82 year old female admitted on 04/08/2019 with a diagnosis of acute ITP (idiopathic thrombocytopenic purpura [disorder that can lead to excessive bruising or bleeding]). Review of the "Mobility" flowsheet dated 04/08/2019 at 1247 revealed Patient #24 had a Morse Fall Risk score of 75 (high risk). Review of the" Fall Interventions/Purposeful Rounding" flowsheet revealed on 04/08/2019 at 2007 Patient #24 was High risk for falls with "10. Bed/chair alarms on at all times unless accompanied by a staff member" documented as an intervention. Review of the medical record revealed Patient #24 was identified as high falls risk throughout the hospitalization.

Observation on 04/11/2019 at 1458 during tour revealed Patient #24 lying in bed. Observation revealed the bed alarm was off and there was no staff in the room.

Interview with the Nurse Manager on 04/11/2019 at 1532 revealed "based on our policy, bed/chair alarms should be on."

4. Review of the medical record for Patient #25 on 04/11/2019 revealed a 58 year old female was admitted on 04/10/2019 with a diagnosis of neutropenic fever (increased susceptibility to infections). Review of the "Mobility" flowsheet dated 04/10/2019 at 1949 revealed Patient #25 had a Morse Fall Risk score of 45 (high risk) . Review of the" Fall Interventions/Purposeful Rounding" flowsheet revealed on 04/10/2019 at 1900 Patient #25 was High risk for falls with "10. Bed/chair alarms on at all times unless accompanied by a staff member" documented as an intervention. Review of the medical record revealed Patient #25 was identified as high falls risk throughout the hospitalization.

Observation on 04/11/2019 at 1458 during tour revealed Patient #25 lying in bed. Observation revealed the bed alarm was off and there was no staff in the room.

Interview with the Nurse Manager on 04/11/2019 at 1532 revealed "based on our policy, bed alarms should be on."

5. Review of the medical record for Patient #26 on 04/11/2019 revealed a 71 year old male admitted on 03/08/2019 at 1905 with a diagnosis of pancytopenia (reduction in red blood cells, white blood cells, and blood platelets). Review of the "Mobility" flowsheet revealed Patient #26 had a Morse Fall Risk score of 45 (high risk) on 03/08/2019 at 1905. Review of the" Fall Interventions/Purposeful Rounding" flowsheet revealed on 03/08/2019 at 1905 Patient #26 was High risk for falls with "10. Bed/chair alarms on at all times unless accompanied by a staff member" documented as an intervention. Review of the medical record revealed Patient #26 was identified as high falls risk throughout the hospitalization.

Observation on 04/11/2019 at 1458 during tour revealed Patient #26 lying in bed with a sign above the bed on the back wall that read "Fall Alarms On at All Times." Observation revealed the bed alarm was off and no staff were in the room.

Interview with the Nurse Manager on 04/11/2019 at 1532 revealed "based on our sign and the policy, bed alarms should be on."

6. Review of the medical record for Patient #28 on 04/11/2019 revealed a 75 year old male admitted on 04/08/2019 at 0727 with a diagnosis of C1Arm A Hyper CVAD [chemotherapy for refractory MM (multiple myeloma)]. Review of the "Mobility" flowsheet revealed Patient #28 had a Morse Fall Risk score of 45 (high risk) on 04/08/2019 at 1050. Review of the "Fall Interventions/Purposeful Rounding" flowsheet revealed on 04/08/2019 at 0743 Patient #28 was High risk for falls with "1. All interventions performed" documented which included bed/chair alarms on at all times unless accompanied by a staff member as an intervention. Review of the medical record revealed Patient #28 was identified as high falls risk throughout the hospitalization.

Observation on 04/11/2019 at 1458 during tour revealed Patient #28 lying in bed. Observation revealed the bed alarm was off and there was no staff in the room.

Interview with the Nurse Manager on 04/11/2019 at 1532 revealed "based on our policy, bed alarms should be on."

7. Review of the medical record for Patient #29 on 04/11/2019 revealed a 77 year old male admitted on 04/02/2019 at 1135 with a diagnosis of intractable midline low back pain due to Multiple Myeloma (type of cancer). Review of the "Mobility" flowsheet revealed Patient #29 had a Morse Fall Risk was a 45 (high risk) on 04/02/2019 at 1135. Review of the "Mobility" flowsheet revealed Patient #29 had a Morse Fall was a 60 (high risk) on 04/03/2019 at 1914. Review of the "Fall Interventions/Purposeful Rounding" flowsheet revealed on 04/03/2019 at 1914 Patient #29 was High risk for falls with "10. Bed/chair alarms on at all times unless accompanied by a staff member" documented as an intervention. Review of the medical record revealed Patient #29 was identified as high falls risk throughout the hospitalization.

Observation on 04/11/2019 at 1458 during tour revealed Patient #29 lying in bed. Observation revealed the bed alarm was off and there was no staff in the room.

Interview with the Nurse Manager on 04/11/2019 at 1532 revealed "based on our policy, bed alarms should be on."

8. Review of the medical record for Patient #20 on 04/11/2019 revealed a 53 year old male admitted on 03/15/2019 at 1436 with a diagnosis of acute respiratory failure with hypoxia (lack of oxygen). Review of the "Mobility" flowsheet revealed Patient #20 had a Morse Fall Risk score of 60 (high risk) on 03/15/2019 at 1439. Review of the "Fall Interventions/Purposeful Rounding" flowsheet revealed on 03/15/2019 at 1920 Patient #20 was High risk for falls with "10. Bed/chair alarms on at all times unless accompanied by a staff member" documented as an intervention. Review of the medical record revealed Patient #20 was identified as high falls risk throughout the hospital stay.

Observation on 04/11/2019 at 1458 during tour revealed Patient #26 lying in bed. Observation revealed the bed alarm was off and there was no staff in the room.

Interview with the Nurse Manager on 04/11/2019 at 1532 revealed "based on our policy, bed alarms should be on."

9. Review of the medical record for Patient #19 on 04/11/2019 revealed an 84 year old female admitted on 04/11/2019 at 1011 with metastatic cancer to dome of urinary bladder and obstructive uropathy (difficulty with urination). Review of the "Mobility" flowsheet revealed Patient #19 had a Morse Fall Risk score of 50 (high risk) on 04/11/2019 at 1011. Review of the "Fall Interventions/Purposeful Rounding" flowsheet revealed on 04/11/2019 at 1011 Patient #19 was High risk for falls with "1. All interventions performed" documented which included bed/chair alarms on at all times unless accompanied by a staff member as an intervention. Review of the medical record revealed Patient #19 was identified as high falls risk throughout the hospital stay.

Observation on 04/11/2019 at 1458 during tour revealed Patient #19 lying in bed with a sign above the bed on the back wall that read "Fall Alarms On at All Times." Observation revealed the bed alarm was off and no staff were in the room.

Interview with the Nurse Manager on 04/11/2019 at 1532 revealed "based on our sign and the policy, bed alarms should be on."

NC00150081; NC00148717