HospitalInspections.org

Based on review of facility documents, facility policy, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a battery was maintained in a chair alarm resulting in a fall with injury for one of 15 medical records reviewed (MR1).

Findings include:

Review on December 9, 2016, of the facility policy "Patient's Rights and Responsibilities" revealed "Article I Introduction It is the policy of Pocono Health System to promote the interests and well being of all patients. It is declared to be the policy of Pocono Health System that the interests of Pocono Health System's patients be protected by a Patient's Bill of Rights. ... Article II Patient Bill of Rights The Board of Directors of Pocono Health System hereby establishes that each patient at Pocono Health system shall enjoy each of the following: ... 6. The right to privacy and to receive care in a safe setting."

Review of facility documents revealed an investigation was completed regarding a fall that occurred on October 10, 2016. The investigation revealed the chair alarm did not sound, as there was no battery in the alarm.

Review of MR1 revealed presentation to the emergency room on October 8, 2016. It was determined it was unsafe to discharge the patient to home. The patient was placed in observation status with the plan to transfer to long term care when a bed was available. One to one observation was instituted due to the patient's high risk of a fall. Nursing flowsheet revealed bed alarm and 1:1 observation. This was maintained from 2053 on October 8, 2016 to October 10, 2016. On October 10, 2016, at 1331 the patient was sitting out of bed in chair with chair alarm in place. The patient was trialed off the one to one. On October 10, 2016, at 1405 the patient found lying on the floor on their back with bloody drainage around the occipital region. A rapid response was called. The patient was transferred to Intensive Care. CAT (computerized axial tomography) scan revealed multiple areas of hemorrhage.

Interview with EMP1 on December 9, 2016, confirmed there was no battery in the chair alarm and that is why it did not go off. EMP1 confirmed MR1 was off the one to one observation for 30 minutes when the fall occurred.