HospitalInspections.org

Based on interview and record review, the facility's registered nurse (RN) did not supervise and evaluate the nursing care for 1 of 1 patient, Patient #1 in that the RN did not apply a chair alarm to Patient #1's wheelchair. Patient #1 was a high risk for falls.

Findings included:

Patient #1 was admitted on 07/18/19 with a past medical history of a cerebral vascular accident with left sided weakness. The Progress Notes dated 07/21/18 at 1315 reflected ..." Pt. (patient) found on the floor in room near bed in sitting position. Pt states she fell on floor hitting lt (left) side while attempting to transfer to bed ..."

The Progress Notes dated 07/31/18 at 2340 reflected ..." Found pt. attempting to get in wheelchair ...reinforced fall precautions ...0430 again is attempting to get in wheelchair on her own she almost fell ..."

The Incident Report dated 08/05/18 at 2025 ..." pt. wandering in chair ...slid to floor from wheelchair ...Pt. AOx2, OOB in WC Propelling, wandering on unit in day hall...pt in day hall verbally states she was trying to transfer to chair and slid to floor as witnessed by housekeeping, other pts, tech, monitor obtain bed alarm, low bed for safety ..."

During an interview on 08/20/18 at 1250 Personnel #1 stated stated that Patient #1 was a high fall risk on admission and should have had a chair alarm at all times; once Patient #1 had her first fall she should have had a bed and chair alarm in place. Personnel #1 stated she did not find any documentation of a chair alarm or bed alarm in use after the first fall.

The fall risk assessment and interventions document reflected patients with a High Fall Risk Score of 106-123 ...Consider bed alarm/chair alarm if patient is impulsive.