HospitalInspections.org

Based on medical record review, policy review, and staff interview the facility staff failed to consistently document the use of bed and chair alarms as indicated on the patient's interdisciplinary plan of care.

Findings were:

Review of medical records on 4/18/16 and 4/19/16 revealed inconsistent documentation of the use of bed alarms and chair alarms on the Daily Flowsheet/Treatment Record. 6 of 10 medical records reviewed revealed documentation on the Interdisciplinary Plan of Care for High Risk Fall Precautions to include: Call light within reach; Bed alarm/chair alarm. Review of medical records for patients #1,#2,#3,#4,#5, and #6 revealed inconsistent documentation of the use of bed alarms and chair alarms on the Daily Flowsheet/Treatment Record identified as high risk fall patients with the intervention on the Plan of Care for the need for bed/chair alarms.

Facility policy titled "Daily Flowsheet/Treatment Record" states in part "The Flowsheet/Treatment Record will be completed each shift by nursing and therapy staff as follows: Safety-Indications for non-restraint measures, bed entrapment prevention measures as well as restraint measures should be accurately reflected. Special Precautions should be marked as appropriate to the patient and hospital policy."

In an interview with the Director of Quality/Risk Management and the Chief Nursing Officer on 4/19/16 both acknowledged the inconsistent documentation of the use of safety measures such as bed/chair alarms on the Daily Flowsheet/Treatment Record.