HospitalInspections.org

I. Based on review of policies, procedures, manufacturer's information, documents, and staff interviews, the hospital failed to ensure administrative staff implemented an action plan to ensure staff used 8 of 8 patient chair alarm pads in accordance with the manufacturer's instructions.

Failure to ensure administrative staff implemented an action plan for the use of chair alarm pads resulted in staff failed to use 8 of 8 fall risk patient chair alarm pads in accordance with the manufacturer's information and could potentially result in patient falls, injuries, and/or harm.

Findings include:


1. Review of policies and procedures failed show evidence of a policy or procedure for the use of chair alarm pads including testing of the chair alarm pads prior to each use in accordance with the manufacturer's instructions.

Review of hospital policy titled "Patient Bill of Rights and Patient Responsibilities Policy", dated 7/2015, revealed in part, ". . . You have the right to receive care in a safe setting. . . ."

2. Review of manufacturer's information titled "AliMed Wireless Sensor System Operator's Manual" included in part, ". . . AliMed 6-Month Chair Alarm Sensor Pads - a wireless sensor system that consists of a patient unit that attaches to the chair alarm pad and a remote unit [that magnetically attaches to the door frame of the patient's room]. . . The system activates when weight is removed from the sensor pad. . . When the Wireless Sensor System is activated, the Patient Unit emits an audible alarm and sends a signal to the Remote Unit to also sound an alarm. . . ."

3. Review of document identified as incident report dated 9/14/15 included in part,"...Patient #9 ...fell and hit her left side...rib region on the arm rail next to the toilet...A chair alarm was in place to the recliner chair, but did not sound...patient sustained left rib fractures..."

Review of document, untitled dated 9/14/15 included in part, "Event...Chair alarm was in place...but did not sound...Immediate Action...Department Discussion...There are instructions on the pad for how to check...working prior to patient setting down...suggest in November competencies...chair and bed alarms be part of that...be on new nurse competencies check off list...begin to date the mats...put in use...remove in 6 months...Action Plan: Chair alarm training with competencies/orientation. Pads be dated and changed out in 6 months usage time..."

4. Review of document titled "Department Report", dated September 16, 2015, from Staff R, Chief Nursing Officer (CNO), revealed in part, Medical/Surgical report - Quality - We will be doing education on the chair alarms, including competency. We are planning to have our competency day in November.

During an interview on 10/14/15 at 4:10 PM, Staff R, Chief Nursing Officer (CNO), stated the Bed Alarm and Chair Alarm information was added to the "Equipment Orientation checklist" on 10/14/15 (during the survey.)

5. During tour of the medical/surgical patient care area on 10/12/15 starting at 2:20 PM with Staff S, Director of Emergency Room/Annex/Medical-Surgical/Special Care Unit, observations revealed patients #1, 2, 3, 4, 5, 6, 7, and 8 were identified as a fall risk by a yellow fall tab visible at each patient doorway to the room and had chair alarm pads in use.

6. Observation of a chair alarm pad showed the manufacturer (AliMed) as "Six-Month Thin Chair Sensor Pads" included instructions printed on the chair alarm pad in part, "Setup Instructions...Record expiration date here (six months from initial use date)...Caution..We recommend that the use of this product does not exceed six months..."

Observations on 10/13/15 at 4:25 PM with Staff C, Risk Management/Patient Safety revealed chair alarm pads for patients # 1, 2, 3, 4, 5, 6, 7, and 8 lacked a date for initial use of the chair alarm pads.

Observations on 10/13/15 at 4:50 PM with Staff R, CNO, and Staff S revealed chair alarm pads for patients # 1, 2, 3, 4, 5, 6,7, and 8 had manufacturer's instructions on the chair alarm pads as follows, "Setup Instructions. . . Record expiration date here (six months from initial use date). . . Caution. . . We recommend that the use of this product does not exceed six months. . . Testing the System. . .Test pad by applying pressure to the pad for three (3) seconds, then releasing. Note: Always test alarm and sensor pad together as a system to ensure proper operation. . . ."

7. Review of hospital documentation titled "Chair Alarm Pads" revealed chair alarm pads for patients # 1, 6, and 7 were received by the hospital on 2/18/15 which was 8 months prior to the survey. Review of this documentation lacked evidence of the date of initial use for chair alarm pads currently in use by patients #1, 2, 3, 4, 5, 6, 7, and 8 at the time of the survey.

8. During an interview on 10/14/15 at 10:05 AM, Staff R, stated the staff did not receive additional training after Patient #9 fell on 9/14/15 because the chair alarm pad was faulty. Staff R reported the hospital did not have a policy or procedure for the use of chair alarm pads it is protocol to use a chair alarm pad for fall risk patients. The CNO stated after the incident on 9/14/15 the hospital did not develop a policy and/or a procedure for staff to test the chair alarm pads prior to each use in accordance with the manufacturer. The CNO reported the Medical/Surgical unit staff attended a mandatory meeting for education on chair alarm usage, however the CNO reported there was no documentation of a sign in sheet for staff attendance or when the meeting occurred.

During an interview on 10/14/15 at 2:30 PM, when asked if staff received training to test the chair alarm pads, Staff V, Registered Nurse (RN), reported one time at a monthly staff meeting prior to July 3, 2015.

During an interview on 10/14/15 at 2:45 PM, when asked if staff received training to test the chair alarm pads, Staff AA, Registered Nurse (RN), and Staff BB, RN, House Supervisor stated the chair alarm pads were not tested prior to each use. RN, stated a couple of months ago chair alarms were reviewed and if staff did not feel comfortable using them or had questions they were to ask. Staff AA stated she had training on chair alarms when she worked as a certified nursing assistant at the hospital prior to becoming a RN.

During interviews on 10/13/15 and 10/14/15 between 1:40 PM and 3:40 PM, 8 of 8 staff each stated they do not document that the chair alarm pads were tested prior to each use to ensure the chair alarm pads were functioning (Staff W, X, Y, Z, AA, BB, CC, and DD)

Based on observation, review of policy, documents, and staff interviews, the hospital administrative staff failed to secure and protect patient information from unauthorized users. The problem was identified for the Health Information Services (HIS) department.

The Facilities Manager reported the Health Information Services department contained approximately 45,000 patient records.

Failure to secure the patient information could potentially cause a misuse of patient information and/or stolen identity for the individual patients.

Findings include:

1. Review of a Health Information Services policy titled, "Securing Filing of Medical Records", revised 3/2013 included in part, "...Medical records shall not be left unattended in areas accessible to unauthorized individuals...Health Information Services is responsible for safeguarding both the record and its information content against loss, defacement, and tampering. They area also responsible to safeguard the medical records against use by unauthorized individuals..."

2. Observations on 10/14/15 at 9:00 AM, during a tour of the HIS department revealed open rolling shelving that held multiple patient medical records. Staff I, Inpatient Coder, reported second shift housekeeping staff cleaned the HIS department after the majority of HIS staff ended their shift. Staff I reported the housekeeping staff used the badge access to enter the HIS department.

3. During an interview on 10/14/15, at 3:55 PM, Staff D Housekeeping, reported she used the badge access to enter the HIS department. Staff D reported an employee from the HIS department is not always present.

During an interview on 10/14/15, at 4:00 PM, Staff E, Housekeeping reported she entered and cleaned the HIS department around 6:00 PM to 7:00 PM with her badge. She reported occasionally Staff K is present in the department, but not always.

During an interview on 10/14/15, at 4:05 PM, Staff F, Housekeeping, reported she cleaned the HIS department after 5:00 PM and entered the HIS department with her badge. Staff F reported she is alone in the HIS department on Tuesday and Friday.

During an interview on 10/14/15, at 4:05 PM, Staff G, Housekeeping, reported she cleaned the HIS department after 7:00 PM and entered the HIS department with her badge. Staff F reported she is alone in the HIS department on Tuesday and Friday.

During an interview on 10/14/15, at 4:15 PM, Staff B, Facilities Manager, acknowledged although, the "Reader Access Level Report" showed housekeeping had restricted access in accordance to the staff interviews, the housekeeping staff had 24 hour access to the IHS department. The Facilities Manager reported all maintenance staff and security are allowed 24 access in case they needed emergency access, during unstaffed hours. Staff B reported he did not see this as a security risk of the patient confidential information in the patient's medical records. Staff B acknowledged housekeeping, maintenance and security did not need access to personal patient information, as part of their job. The Facilities Manager reported the HIS rolling shelves could be locked, but the department staff currently did not lock them when the department is unattended.

Review of a document titled "Transaction Reports", dated 10/15/15, revealed the report identified dates and times of employee badge use, to enter the HIS department, from 10/1/15 through 10/15/15. The report identified 26 incidents of badge access into the department by housekeeping employees after 5:00 PM and 18 of the incidents occurred on Tuesdays or Fridays, after 4:30 PM.

During an interview on 10/15/15, at 11:30 AM, Staff L, Vice President of Compliance/Employee Operations/Privacy Officer acknowledged housekeeping, maintenance and security employees do not require to have access to patient information to perform their job duties. Staff L reported those employees would be considered unauthorized users. Staff L reported she trusted the hospital employees regarding access to patient information, so from that perspective she does not view the unrestricted access to patient records in HIS a concern

Based on observations, review of policies, procedures, manufacturer's information, documentation, and staff interviews, the hospital failed to ensure staff single patient use chair alarm pads were used for only one patient in accordance with the manufacturer's instructions for 5 of 8 patients. (Patients # 2, 3, 4, 5, and 8) The hospital identified a current census of 25 patients at the start of the survey.

Failure to ensure single use chair alarm pads were used for only one patient could potentially allow patients to be exposed to infectious diseases and cause severe illness to the patient.

Findings include:

1. Review of hospital policy/procedure titled "Disinfection Guidelines", dated 6/15, revealed in part, "Disposable single use patient care items will be used once. Disposable items may not be cleaned and reused. . . ."

2. Review of undated manufacturer's information titled "AliMed Wireless Sensor System Operator's Manual" revealed in part, ". . . AliMed 6-Month Chair Alarm Sensor Pads - a wireless sensor system that consists of a patient unit that attaches to the chair alarm pad and a remote unit [that magnetically attaches to the door frame of the patient's room]. . . ."

3. During tour of the medical/surgical patient care area on 10/12/15 starting at 2:20 PM with Staff S, Director of Emergency Room/Annex/Medical-Surgical/Special Care Unit, observations revealed 8 patients identified as a fall risk by a yellow fall tab visible at each patient doorway to the room and had chair alarms in use. During tour of the store room, Staff S stated chair alarm pads were kept in the store room after they had been cleaned/disinfected following patient discharge and would be ready for use for the next patient that needed a chair alarm.

4. Observations on 10/13/15 at 4:50 PM with Staff R, Chief Nursing Officer (CNO), and Staff S revealed chair alarm pads for patients # 2, 3, 4, 5, and 8 had manufacturer's instructions on the pads as follows, "Caution . . . Sensor pad is intended to be used for individual patients only. . . Care and Maintenance . . . Sensor pad is for single patient use only. . . ."

Review of documentation on chair alarm pads for patients #2, 3, 4, 5, and 8 were identified by the manufacturer (AliMed) as "Six-Month Thin Chair Sensor Pads" included instructions on the chair alarm pad in part, ". . .Caution . . . Sensor pad is intended to be used for individual patients only. . . Care and Maintenance . . . Sensor pad is for single patient use only. . . ."


5. During an interview on 10/13/15 at 4:50 PM, Staff R and Staff S acknowledged neither staff knew the chair alarm pads for patients # 2, 3, 4, 5, and 8 had manufacturer's instructions on the chair alarm pads for single patient use only and reported the chair alarm pads were disinfected and reused on multiple patients.

During an interview on 10/13/15 at 5:00 PM, Staff B, Facilities Manager, acknowledged he was not aware the chair alarm pads for patients # 2, 3, 4, 5, and 8 had instructions for single patient use.

During an interview on 10/14/15 at 7:50 AM, Staff Y, Certified Nursing Assistant (CNA), stated the chair alarm pads are cleaned with disinfectant wipes after a patient is discharged and then placed in a plastic bag to store in the store room so the pad was ready for the next patient. Staff Y reported the chair alarm pads were used for more than one patient, we go to the store room to get a chair alarm pad stored in a plastic bag when needed for the next patient.

During an interview on 10/14/15 at 8:05 AM, Staff Z, Certified Nursing Assistant (CNA), stated the chair alarm pads are cleaned with disinfectant wipes after a patient is discharged and then placed in a plastic bag to store in the store room so the chair alarm pad was ready for the next patient. Staff Y reported the chair alarm pads were used for more than one patient, when need a chair alarm pad it is obtained from the store room where they are stored in a plastic bag.

During an interview on 10/13/15 at 3:15 PM, Staff EE, Biomedical Technician, stated biomed staff changed a plug on one chair alarm pad and placed the pad back in use but did not date the pad since the pad had already been in use.

Review of hospital documentation received 10/14/15 at 7:30 AM revealed a "Detailed Equipment History Report" from biomedical technician revealed on 1/19/15 biomedical staff documented "Reported that unit 'Did Not Work'. Found that plug had been torn loose on the chair mat. Replaced plug and tested unit. Returned to service 1/19/15".