HospitalInspections.org

Based on document review and interview, it was determined for 2 of 4 (Pt#1 and Pt #9) patients who had falls with bed alarms in place, the Hospital failed to ensure the appropriate fall precautions were in place and equipment was functioning properly.

Findings include:

1. The Hospital policy entitled "Falls Prevention and Post Fall Management Program" (reviewed 08/11/15) was reviewed on 12/14/15 at approximately 12:00 pm and required, "...All patients identified at "high fall risk" for falls should have the standard interventions and...will have an individualized fall prevention plan in place to reduce the risk of falls/injury...Interventions appropriate to the patient's risk factors..."

2. The clinical record for Pt #1 was reviewed on 12/14/15 at approximately 11:00 am and included Pt #1 was a was an 86 year old female admitted to the Hospital's progressive care unit (PCU) on 10/23/15 with a diagnosis of altered mental status. Pt #1's fall risk assessment, dated and timed 10/24/15 at 9:15 am, completed by E #1 (RN) included Pt #1 scored a "5" (high risk for falls), and a bed alarm was in use. E #1's note, dated and timed 10/24/15 at 4:45 pm, indicated Pt #1 had an unwitnessed fall at 4:45 pm, and a rapid response was called. E #1's post fall assessment at 4:50 pm included, "...Patient was laying on floor near the sink after falling and a nurse and CNA [cerified nurse's assistant] were with her...Patient stated she got up because she had to go to the bathroom and she felt it was urgent...Alarm device in use..." A CT (computerized tomography) of the head, and x-rays of the hip, cervical spine, and elbow were ordered. The hip x-ray indicated Pt #1 had a fractured right hip.

The Post Fall Huddle Form dated and timed 10/24/15 at 5:20 pm included: the bed alarm was in use, but the alarm did not sound prior to Pt #1's fall. Attendees of the post fall huddle included the House Supervisor, PCU Charge Nurse, E #1, and the CNA.

3. On 12/16/15 at approximately 9:28 am, an interview was conducted with E #1' s nurse preceptor (E #10). E #10 was the first to respond to the fall. E #10 stated that she heard Pt #1's fall, but no bed alarm had sounded. Pt #1 was on high risk fall precautions, and the bed alarm was activated (light on) when E #10 entered Pt #1 ' s room. E #10 stated Pt #1 had some dementia and never used the call light. E #10 stated they tested the bed alarm when they were transferring Pt #1 back into the bed after the fall. The first level sensor, which senses movement around the perimeter of the bed, was not alarming with movement. This would be the level which activates upon exiting the bed. E #10 stated the bed was sent to engineering, and Pt #1 was moved to a new bed.

4. The clinical record for Pt #9 was reviewed on 12/15/15 at approximately 12:55 pm. Pt #9 was an 88 year old female admitted to the PCU on 11/18/15 with diagnoses of generalized weakness, fall, and loss of coordination on the right hand. E #12's fall risk assessment, dated and timed 11/19/15 at 9:01 am, indicated a score of "6" (high risk for falls), and a bed alarm was in use.

The post fall huddle form dated 11/19/15, completed by E #12, inlcuded, "...Alarm system in use...Alarm did not sound prior to fall...Recommendations:...Sitter assigned...Patient found on floor in supine position...Rapid response called. Manager notified. Patient complained of [right] wrist pain, as well as [right] hip and back pain...Bed was taken out of service and maintenance checked alarm and said that all working..."

Pt #9 sustained a right wrist fracture as a result of the fall and was discharged to the acute rehabilitation unit on 11/24/15.

5. On 12/15/15 at approximately 11:35 am, an interview was conducted with the PCU Nurse Manager (E #3). E #3 stated that the bed alarm did not sound when Pt #1 fell. E #3 stated that following the fall, the bed was sent to engineering, and Pt #1 was switched to a different bed. E #3 stated Pt #9's bed alarm did not sound prior to her fall. The bed was sent to engineering following the fall, and no alarm problems were identified. E #3 stated when a patient is confused, a sitter would be an appropriate fall prevention intervention, and a sitter was put in place following Pt #9's fall.

6. On 12/15/15 at approximately 3:00 pm, an interview was conducted with the Regional Quality Lead (E #6). E #6 stated that the hospital has a review of falls with injuries scheduled for 12/22/15 (confirmed with documentation of agenda) where the clinical records, fall risk assessments and precautions, and related policies and procedures will be reviewed for identification of process improvement opportunities. However, at the time of this survey (12/15/15), no changes had been put in place to prevent additional falls related to possible equipment malfunction identified on 10/24/15, when Pt #1 ' s bed alarm did not sound prior to the fall.

Based on document review and interview, it was determined for 4 of 5 clinical records reviewed (Pts #6, 11,12, and 13) for patients who had blood transfusions, the Hospital failed to ensure vital signs were documented as required by policy.

Findings include:

1. On 12/15/15 at 9:30 am, Hospital policy 7.5, titled, "Transfusion Therapy - Administration of Blood & Blood Components/ Massive Transfusion (adults 18 years and older), revised 9/16/10, was reviewed. The policy required, (pg. 7) "...Take and record vital signs before the transfusion, 15 minutes after the start of the transfusion...30 minutes and then hourly until transfusion is complete...one (1) hour after the completion of the transfusion..." (pg. 11), "Documentation: Document the following in the patient's medical record... Vital signs prior to the infusion, 15 minutes after beginning the transfusion, at 30 minutes and at the completion of transfusion and four (4) hours after initiating transfusion..."

2. On 12/15/15 at 9:20 AM, Pt. #6's clinical record was reviewed. Pt. #6 was a 62 year old female, admitted to the hospital's intensive care unit (ICU) on 12/11/15, with diagnoses of shortness of breath, hypoxia, and tachycardia. A physician's order dated 12/14/15 included 1 unit of packed red blood cells (PRBCs) to be transfused. Pt. #1's blood transfusion record included a start time of 12:57 PM and a completion time of 3:15 PM. The transfusion administration record included vital signs at 12:57 PM, 1:15 PM, 2:15 PM, and 3:15 PM. The vital signs required 30 minutes after the start of the transfusion were missing.

3. Pt #11's clinical record was reviewed on 12/16/15 at approximately 9:00 am. Pt #11 was a 52 year old female, admitted to the hospital's oncology unit on 12/11/15. with diagnoses of anemia and hypergyncemia. A physician's order dated 12/11/15 required the transfusion of 2 units of PRBCs. The transfusion record for the first unit included a start time of 6:45 pm and a completion time of 9:00 pm. The vital signs required one hour after completion were missing. The transfusion record for the second unit of PRBCs included a start time of 11:04 pm and a completion time of 2:40 am. The vital signs required one hour after completion were missing.

4. Pt #12's clinical record was reviewed on 12/16/15 at approximately 9:20 am. Pt #12 was a 60 year old male, admitted to the hospital's Progressive Care Unit on 10/20/15, with diagnoses of weakness and altered mental status. A physician's order dated 10/21/15 required the transfusion of 1 unit of PRBCs. The transfusion record included a start time of 10:04 pm and a completion time of 1:10 am. The vital signs required at 30 minutes were 8 minutes late, and the vital signs required one hour after completion were missing.

5. Pt #13's clinical record was reviewed on 12/16/15 at approximately 9:30 am. Pt #13 was a 43 year old male, admitted to the hospital's oncology unit on 11/3/15, with diagnoses of anemia and pneumonia. A physician's order dated 11/3/15 required the transfusion of 2 units of PRBCs. The transfusion record for the first unit included a start time of 3:52 am and a completion time of 7:00 am. The required 30 minute vital signs were 5 minutes late and the one hour after completion vital signs were missing. The transfusion record for the second unit included a start time of 10:45 am and a completion time of 1:48 pm. The 30 minute vital signs were 8 minutes late, and the one hour after completion vital signs were missing.

6. On 12/15/15 at 2:00 PM, an interview was conducted with the Regional Quality Lead (E #6). E #6 stated that the policy was a corporate policy and the required documentation of vital signs is worded differently in two separate parts of the policy.

7. On 12/16/15 at approximately 9:30 am, E #6 provided the surveyor with a printout of the computer template used for the electronic blood transfusion record which is completed by the nurse. The transfusion record included prompts to document vital signs at start of transfusion, every 15 minutes twice (15 minutes and 30 minutes after start), then hourly until transfusion complete. The electronic blood transfusion record template did not include a place or prompt for vital signs one hour after completion of transfusion.

8. Duiring an interview with the Regional Lead Risk Management (E #11) on 12/16/15 at approximately 11:30 am, E #11 stated that the blood transfusion policy needed to be revised to reflect the required vital signs which are in practice, the corporate office had been notified, and they are revising the policy for review immediately.