HospitalInspections.org

Based on interview and record review, the facility failed to ensure corrective measures to maintain patient safety and decrease the risk of patient's pulling out medical devices included the rehabilitative (rehab) and respiratory services staff, resulting in the potential for reoccurrence and poor patient outcomes. Findings include:

On 1/28/19 at 1130 an interview was conducted with the Director of Nursing (Staff B). She explained there had been more recent patient self dislodgements of medical devices.
She said her nursing staff had been inserviced She said we hold daily huddles following patient dislodgements with the team. A review of sign in sheets revealed only nursing staff had been inserviced.

An interview was conducted with the Staff Educator (Staff L) on 1/29/19 at 1220 while accompanied by the DON. Staff L was asked to provide evidence that documented the rehab staff and the respiratory staff were in-serviced on corrective measures to maintain patient safety and prevent patient's from pulling out medical devices. Staff L stated, "They were not." She stated, "They are contracted services". She said their companies would be responsible for their training and in-services.

At that time the DON was asked to explain why therapy staff and respiratory staff were not included in the in-services to promote patient safety and decrease the risk for patient's pulling out medical devices. She said I will have to do that.