HospitalInspections.org

Based on medical record review, document review, and interview, the facility did not notify Patient #1's representative about a change in his health status, specifically, a fall while hospitalized. Lack of notification can prohibit decision making and informed consent related to Patient #1's care and treatment.

Findings Include:

Review of Nursing progress note dated 01/04/22 at 06:21 AM revealed the nurse called Patient #1's wife to updated her that Patient #1 had fell on 01/02/22 at 5:30 PM. The wife requested that she be called with updates for any acute changes.

Review of Social Worker progress note dated 01/04/22 at 08:47 AM revealed Patient #1's wife had phoned her and was upset that she was not notified of Patient #1's fall on 01/02/22.

Review of Physician progress note dated 01/04/22 at 05:00 PM revealed he spoke with Patient #1's wife who was upset that the facility did not communicate with her regarding the fall on 01/02/22. The wife revealed she did not call for a status update on Patient #1 on 01/02/22 as she was caring for family members who were sick with Covid.

Review of Incident Report for the fall that occurred on 01/02/22 at 05:30 PM revealed Patient #1 got out of his chair unassisted, and the bed alarm sounded. The Patient Care Tech (PCT) responded, emergently from hallway, after donning PPE due to Patient #1's positive Covid status. Patient#1 was taking himself the bathroom without assist. Patient #1 began to lose his balance in the bathroom and the PCT lowered him to the ground.

Interview with Staff (A) Senior Director of Clinical Regulatory Compliance on 07/13/22 at 01:30 PM, verified these findings.

Based on medical record review, document review, and interview, Patient #1 did not receive care in a safe setting. Specifically, the bed alarm did not activate to alert staff that Patient #1 was attempting to get out of the chair. Failure of the alarm to activate resulted in Patient #1 falling and sustaining scratches to his upper back.

Findings Include:

Review of Physician progress note dated 01/10/22 at 09:12 AM revealed Patient #1 was much more alert today. Patient #1 is alert to self and place, but cognition is impaired. Will have a trial removal of the lap restraint today.

Review of Physician's Assistant (PA) progress note dated 01/10/22 at 05:30 PM revealed staff called the PA to see Patient #1 for a reported fall. Staff reported Patient #1 was sitting in a chair, leaned forward to get his cane, and ended up sitting on the floor. Patient #1 denied hitting his head but sustained several scratches to his upper back. Patient #1 had a chair alarm on, but the alarm did not sound until after he was assisted back to the chair. The wife was called and informed of trial removal of the restraint, but that the restraint belt will be reapplied for patient safety.

Review of Event Report for the fall that occurred on 01/10/22 revealed the bed/chair alarm did not activate when Patient #1 attempted to get up to reach his cane. The patient lap restraint was off for a trial. The bed/chair alarm was replaced and is in current functioning capacity.

Interview with Staff (A) Senior Director of Clinical Regulatory Compliance on 07/12/22 at 01:30 PM, verified these findings.