HospitalInspections.org

Based on interviews and document review, it was determined the facility failed to support a safe environment by placing a fully dependent patient with an elevated fall risk in a wheelchair with unlocked arm rest and loose lateral support and neglected to activate ordered wheelchair belt alarm for one (1) of three (3) patients reviewed.

The findings include:

On 02/13/24 at 10:17 am, the surveyor initiated a review of Patient #1's medical record with the assistance of Staff Member #1. The History and Physical (H&P) documentation stated that Patient #1 was admitted for intensive rehabilitation therapy services following a stroke and had right-sided hemiparesis (significant weakness on right side per Cleveland Clinic).

The patient was determined to be at an elevated fall risk potential as referenced on the interdisciplinary care team (IDT) Plan of Care documentation, "High Risk Precautions".

The admitting physical therapy (PT) evaluation stated that Patient #1 was "wheelchair bound" with a "low" level of physical and cognitive functioning and required "max assist" from staff due to being fully dependent with right-sided "flaccidity" and "decreased sitting balance".

The admitting physician had ordered the patient to have the appropriate self-releasing belt alarm while in wheelchair amongst other fall precautions.

A nursing note with date and time of service of 12/26/23 at 2:30 pm by Staff Member #9 indicated a "Post Fall Assessment" which stated in part, "Patient sitting up at nurses' station in wheelchair, noted leaning toward right side, noted slid to floor from wheelchair, no seatbelt, no armrest noted on wheelchair. Patient expressive aphasic and unable to answer questions asked, patient was sent to... ER via 911".

On 02/13/24 at 3:07 pm, the surveyor met with Staff Member #13 for interview. Staff Member #13 confirmed that following the patient's fall on 12/26/23, they were consulted to immediately assess the wheelchair. Staff Member #13 stated they had determined that the patient was able to fall from the right side of the wheelchair as the right side arm rest was unlocked, and the right side of lateral support was "loose".

On 02/13/24 at 3:19 pm, Staff Member #1 added that, it was determined that the Posey alarm on the patient's self-releasing Velcro belt had never sounded as it was never activated. Staff Member #1 confirmed that safety alarms should be tested and verified to be functional and active prior to use according to facility procedures.

Staff Member #1 provided the surveyor with the facility Policy #677 titled, "Fall Prevention Program" (with last review date of 08/30/23). On page two (2) of document, the policy stated, in part, "Upon admission, plan of care for fall prevention will be initiated to include at a minimum ...self-releasing alarmed wheelchair belts".

On 02/13/24 at approximately 10:30 am, the surveyor reviewed the Policy #120 titled, "Therapeutic Equipment" (with last review date of 05/25/23) provided by Staff Member #1. The policy stated, in part, "The hospital will maintain medical equipment, facilitate, and monitor staff training, and ensure safe use of medical equipment. Clinicians will be trained prior to equipment use, following manufacturers' guidelines or general accepted standards of practice..."

The same policy continued to state, in part, under "Staff Use of Medical Equipment" section of page two (2), "Staff will follow manufacturer's guidelines related to safety", "checks equipment for safety prior to patient use..."