HospitalInspections.org

Based on record reviews and staff interviews, the hospital failed to ensure outpatient services meet the needs of patients in accordance with acceptable standards of practice. This deficient practice was evidenced by failing to ensure a patient's (#1) safety during transfer from a wheelchair to a stretcher for 1 of 5 sampled patients.
Findings:

Review of the hospital's Clinical Practice Guideline, Skills: Fall Prevention and Management - Ambulatory/Outpatient areas revealed, in part:
Many patients seen in the ambulatory setting are at an increased risk for falls related to physiologic factors, treatment, and unfamiliar environmental factors. The best way to prevent falls is to carefully identify those patients that are at risk to fall.

Review of the hospital's Safe Patient Handling: Preventing Injury to Patients and Employees training that was provided to staff August 2018 and May 2019 revealed the content of the training was patient falls. Further review of the training revealed, in part: Safety Precautions must be in place at all times to ensure patient safety throughout the perioperative phases of care:
Assess patient to determine number of personnel required for safe patient transfer.
CDC: Assess the patient and plan for safe transfer to/from OR bed. An adequate number of personnel should be available to ensure patient and personnel safety during transfer.
AORN: Utilize mechanical assistive technology (e.g. lateral transfer device) with a minimum of 3 caregivers for all patients weighing greater than 75 lbs. and a minimum of 4 caregivers for all patients weighing greater than 157 lbs.

Review of Patient #1's medical record revealed he was 6' 4" tall and weighed approximately 259 lbs. The patient had a medical history of cervical stenosis and cervical myelopathy and sustained a fall in 2011 and became an incomplete quadriplegic. The patient was able to move upper arms, but unable to move lower extremities. The patient was scheduled for insertion of spinal cord stimulator in the hospital's (outpatient) Day of Surgery Center on 06/25/19.

Review of Patient #1's medical record revealed S5RN documented the following on 06/25/19: Patient is a partial quadriplegic and required assistance to get out of wheelchair and into stretcher. Patient normally moves self from wheelchair to stretcher via personal slide board. Stretcher was too high for him to use his slide board. ORA's were called to assist with moving patient. Patient 6'4" tall and approximately 259 pounds per patient. One ORA came to bedside. Assistance was offered, ORA stated "I got it. I'm strong enough. We're just going to pivot from the chair to the bed (speaking to patient). Just put your arms around my neck real tight". Patient only has complete mobility control in left arm and paralyzed right hand. Patient was pulled up out of chair by ORA. ORA called out for help as patient began to slide down to floor. Two more ORA's came to bedside along with patient sister and brother in law to assist patient up into stretcher, unsuccessfully. Patient was assisted to floor onto right knee. Patient complains of pain to right knee with mild swelling and redness.

Review of Patient #1's CT of right knee done on 06/25/19 revealed, in part, Impression:
Recent fracture without significant displacement involving the anterior aspect of the proximal tibia, likely including articular surface of the plateau.

In an interview on 08/19/19 at 1:39 p.m., S5RN indicated on 06/25/19 she called for ORA assistance with transferring Patient #1 from his wheelchair to the stretcher. S5RN indicated S6ORA, S7ORA, and S8ORA came to assist with the transfer. S5RN confirmed S8ORA attempted to transfer Patient #1 without any assistance from herself, S6ORA, and S7ORA. S5RN confirmed Patient #1 was helped to the floor and onto his right knee and complained of right knee pain.

During interview on 08/20/19 at 9:08 a.m., S2AVP Performance Improvement, S3Director of Peri-operative Services, and S4AVP Peri-operative Services confirmed Patient #1 required more than one staff member to safely transfer from his wheelchair to stretcher. S2AVP Performance Improvement, S3Director of Peri-operative Services, and S4AVP Peri-operative Services indicated S8ORA should have waited for assistance from S5RN, S6ORA, and S7ORA before transferring the patient. S2AVP Performance Improvement, S3Director of Peri-operative Services, and S4AVP Peri-operative Services confirmed Patient #1 had a right tibia fracture.