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PRESENCE SAINT JOSEPH MEDICAL CENTER 333 N MADISON ST JOLIET, IL 60435 Feb. 28, 2013
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on document/record review and interview it was determined for 4 of 6 Patients (Pt #1, #4, #5, and #6) on fall precautions, the Hospital failed to ensure staff document fall assessments in accordance with policy. Findings include:

1. On 2/28/13 at approximately 2:00 PM the policy titled,"Fall Prevention Program" revised 02/21/11 was reviewed and stated in part, "...The Registered Nurse and /or appropriate healthcare provider will assess all patients/residents for fall risk based on risk factors upon entry to the hospital, home care or long- term care setting. Inpatient reassessment to be completed each shift and with changes to patients condition...."

a) On 02/26/13 at approximately 11:10 AM the clinical record for Pt. #1 was reviewed. Pt. #1, an [AGE] year old male presented to the Hospital's emergency department (ED) on 11/21/12 at 6:30 AM with complaints of abdominal pain. The ED physician documented a normal neurological exam on 11/21/12 at 6:30 AM. Admitting diagnoses included Congestive Heart Failure, Pulmonary Edema, Exacerbation of Chronic Obstructive Pulmonary Disease and Abdominal Pain. Pt. #1 was admitted to the telemetry unit 2W for continuous cardiac monitoring on 11/21/12 at 7:30 AM. The admission nursing assessment dated [DATE] at 7:30 AM documented a history of "confusion at times since September 2012." The nursing neurological assessment dated [DATE] at 8:00 AM documented, "Alert and oriented x3 with symptoms of forgetfulness". A fall risk assessment completed on 11/21/12 at 8:00AM identified Pt. #1 with "dizziness" and at high risk for falls (level 5). Documented safety interventions included application of a bed alarm. Pt#1 remained high risk for falls on 11/22/12, 11/23/12 and 11/24/12 with a bed alarm in place. A fall re-assessment documented on 11/24/12 at 8:30 AM listed Pt. #1 as forgetful/ alert and oriented times three with a high risk assessment for falls (level 5) with bed alarm in place. Nursing failed to complete a fall assessment between 7:00 PM and 12 midnight on 11/24/12 although other computer screen assessments were completed such as IV, pain,dietary and hygiene. On 11/25 at 4:50 AM nursing documented was found "laying on back holding head."

b) Pt. #4, an [AGE] year old male, was admitted [DATE] at 11:27 PM with diagnosis of Dementia/Aggressive behavior. On 2/28/13 at 8:00 AM, Pt. #4's fall score was calculated. On 02/28/13 during record review, a reassessment was documented as being completed on 02/27/13 at 8:00 AM. The record was silent for a second re-assessment between 8:00 AM and 11:59 PM.

c) Pt. #5, an [AGE] year old female, admitted [DATE] at 11:27 PM with diagnosis of Sacral Decubitus ulcer and Leukocytosis. On 02/28/13 at 8:00 AM, Pt. #5's fall score was calculated. On 02/28/13, during record review, reassessments were documented as being completed once per day on 02/20/13 at 8:00 AM and on 02/22/13 at 9:00 AM. The record was silent for second reassessment on these dates.

d) Pt. #6, a [AGE] year old male, admitted [DATE] with diagnosis of Acute Back Pain/Left Hip Pain. On 02/28/13, Pt. #6's fall risk score was calculated. On 02/28/13, during record review, a reassessment was documented as completed on 02/26/13 at 8:11 AM; no second reassessment for that date was recorded.

2. On 02/26/13 at approximately 12:10 PM the Patient Care Manager (E#2) of 2 West was interviewed. E#2 stated that the nurses work 12 hrs shifts, 7 AM to 7 PM and it is expected that a fall risk assessment be documented for each 12 hr shift. E#2 verified that the clinical record for Pt. #1 lacked a fall risk assessment for the PM shift on 11/24/12.

3. During record review while accompanied by E#8, it was noted fall risk assessments were not documented as having been conducted in accordance with policy for Pt. #4, Pt. #5 and Pt. #6.

B. Based on document/record and interview, it was determined for 1 of 1 patient (Pt. #1) who sustained a fall with injury, the Hospital failed to ensure telemetry staff notified unit 2 East when Pt. #1's was off telemetry monitor. Findings include:

1. On 02/26/13 at approximately 11:10 AM the clinical record for Pt. #1 was reviewed. Pt. #1, an [AGE] year old male presented to the Hospital's emergency department (ED) on 11/21/12 at 6:30 AM with complaints of abdominal pain. Admitting diagnoses included Congestive Heart Failure, Pulmonary Edema, Exacerbation of Chronic Obstructive Pulmonary Disease and Abdominal Pain. Pt. #1 was admitted to the telemetry unit 2W for continuous cardiac monitoring on 11/21/12 at 7:30 AM. On 11/25 at 4:50 AM nursing documented a post fall assessment. The assessment included ,"time of fall 0450, was fall witnessed no, laying on back holding head, Pt orientation person, neurological symptoms confused, pupils equal and reactive to light, muscle strength severe weakness, right side of abdomen is distended and swollen, left eye has hematoma and x2 lacerations noted, vital signs taken, confused and disoriented, alarm device in use, bed in low position, brakes on bed, walking area clear and dry physician notified yes."

2. On 02/28/13 and 02/29/13 the Responder Network Report was reviewed with Patient Care Manager (E#2) of 2W. The log dated 11/25/12 at 4:38 AM documented a bed exit alarm sounded and a nurse phone page activated. The alarm was attended to within 4 seconds with the transaction completed within 14 seconds. There was no other documented bed exit alarm between 4:38 AM on 11/25/12 until the time of Pt. #1's fall at 04:50.

3. E#5, (Registered Nurse) caring for Pt. #1 on 11/25/12 during the 7:00 PM to 7 AM shift, was interviewed by telephone. E#5 who stated she walked by Pt.#1's room and observed Pt. #1 in bed approximately 10 minutes prior to Pt. #1's fall. A CNA (E#6) called for assistance at 0452 after finding Pt. #1 on the floor next to a sink. Pt. #1's bed alarm was "flashing but not sounding" according to E#5. Pt. #1's telemetry monitor was off. E#5 stated the telemetry staff did not inform her Pt. #1 was off monitor.

4. E#6 (CNA) was interviewed by telephone on 02/27/13 at approximately 11:30 AM. E#6 stated, " I walked into his room to take his vitals and when I walked in he was on the floor by the sink. I noticed the alarm was flashing but no alarm sounded. The nurse was outside the room so I called her and before we got him back to bed the nurse checked the bed monitor by pushing the alarm button and it was working. It seemed to malfunction that one time. Tele called around 12 midnight to say he was off monitor but during the fall they did not call."

5. E#10 (Telemetry Technician) on duty during the time of Pt.1's, was interviewed by telephone on 2/28/13 at approximately 9:00 AM. E#10 stated," I do recall any problem with this patient. If we have a patient come off the monitor, we call the CNA first and then the RN."

6. E#9 (Telemetry Technician) on duty during the time of the fall was interviewed by telephone on 2/28/13 at approximately 9:15 AM. E#9 stated if a patient comes off the monitor we contact the CNA and if the CNA cannot be reached the RN is contacted by phone. E#9 stated," I can't say that I remember any patient fall."

C. Based on an observational tour, document/record and staff interview, it was determined for 5 of 5 patients (Pt. #7, #8, #9, #10 and #11) on falls precautions, the Hospital failed to ensure 5 of 5 beds alarms were fully functional. Findings include:

1. On 2/28/13 at approximately 10:30 AM to 11:30 AM an observational tour was conducted on PCU 4 East with E#11 (Interim Manager of 4 East). Patients #7, #8, #9, #10, and #11 were observed in their beds. The foot of each bed indicated a bed alarm was in the on position. However, the beds did not include an attached electrical cord from the bed to the wall which would alarm at the nurse's station, activate a flashing light above the patient's door and signal a problem on the nurse's portable phone. Three of 4 safety functions were not in use.

2. The clinical record for Pt. #7 was reviewed on 02/28/13 at approximately 1:45 PM. Pt. #7, a [AGE] year old male, was admitted to room 433 on 2/5/13 with a diagnosis of Chest Pain. The initial nursing assessment dated [DATE] list Pt #7 as a high risk for falls due to confusion and disorientation. Documented fall prevention interventions included "bed alarm". During an observation a tour on 02/28/13 at approximately 10:40 AM, Pt. #7 was observed in room 433, lying on a bed (serial # 5178) with a bed alarm in the on position. The cord from the bed that attaches to the wall (electrical source) was missing rendering 3 of 4 safety components not in use.

3. The clinical record for Pt. #8 was reviewed on 02/28/13 at approximately 1:50 PM. Pt. #8, a [AGE] year old female was admitted on [DATE] with a diagnosis of Respiratory Distress. The initial nursing assessment dated [DATE] listed Pt. #8 as a high risk for falls due to left sided weakness. During an observation a tour on 2/28/13 at approximately 10:40 AM, Pt. #7 was observed in room 403 lying on a bed (serial # 5335) with a bed alarm in the on position. The cord from the bed that attaches to the wall (electrical source) was missing rendering 3 of 4 safety components not in use.

4. The clinical record for Pt. #9 was reviewed on 02/28/13 at approximately 1:55 PM. Pt. #9, a [AGE] year old female was admitted on [DATE] with a diagnosis of Diarrhea. The initial nursing assessment dated [DATE] listed Pt. #9 as a high risk for falls due confusion and disorientation. During an observation a tour on 2/28/13 at approximately 10:45 AM, Pt. #9 was observed in room 408 lying on a bed (serial # 5323) with a bed alarm in the on position. The cord from the bed that attaches to the wall (electrical source) was missing rendering 3 of 4 safety components nonfunctional.

5. The clinical record for Pt. #10 was reviewed on 02/28/13 at approximately 2:00 PM. Pt. #10, a [AGE] year old male was admitted on [DATE] left sided weakness. The initial nursing assessment dated [DATE] listed Pt. #10 as a high risk for falls due confusion and disorientation. During an observation a tour on 2/28/13 at approximately 11:00 AM, Pt. #10 was observed in room 436 lying on a bed (serial # 5329) with a bed alarm in the on position. The cord from the bed that attaches to the wall (electrical source) was missing rendering 3 of 4 safety components nonfunctional.

6. The clinical record for Pt. #11 was reviewed on 02/28/13 at approximately 2:10 PM. Pt. #11, a [AGE] year old female was admitted on [DATE] with diagnosis Tachycardia and Vomiting. The initial nursing assessment dated [DATE] listed Pt. #10 as a high risk for falls. During an observation a tour on 2/28/13 at approximately 11:00 AM, Pt. #11 was observed in room 437 lying on a bed (serial # 677) with a bed alarm in the on position. The cord from the bed that attaches to the wall (electrical source) was missing rendering 3 of 4 safety components nonfunctional.

7. The Nurse Manager for PCU 4 East (E#17) was interviewed on 02/28/13 at approximately 10:45 AM. E#17 stated the beds are checked by nursing to ensure the beds are functional. E#17 was not aware the beds in rooms 433,403, 408, 436 and 437 did not have attached bed cords. E#17 stated without the cords, the beds would only alarm in the patient's room.