HospitalInspections.org

Based on observation, record review, and interview, the facility failed to ensure the right to receive care in a safe setting, in that,

3 of 9 high risk patients checked (Patient #3, #4, and #5) did not have their bed/chair alarms activated for safety.

Findings

During a tour of the patient care areas on 9/11/2023 at 1:45 PM, Personnel #1, #2, and #5 were present and confirmed the following:

Patient #3 had a High Fall Risk score of 55. She did not have a bed/chair alarm activated.

Patient #4 had a High Fall Risk score of 65. She did not have a bed/chair alarm activated.

Patient #5 had a High Fall Risk score of 50. He did not have a bed/chair alarm activated.

During an interview while touring on 9/11/2023 at 1:45 PM, Personnel #1, #2, and #5 Personnel #5 checked the bed/chair alarm for Patient #3 and confirmed it was not set. Personnel #5 asked Patient #3 if Therapy had just brought her back from therapy. Patient #3 stated yes.

Personnel #5 checked the bed/chair alarm for Patient #4 and confirmed it was not set. Personnel #1 asked Patient #4 if Therapy had just brought her back from therapy. Patient #4 stated yes.

Personnel #5 checked the bed/chair alarm for Patient #5 and confirmed it was not set. Personnel #5 asked Patient #5 if Therapy had just brought him back from therapy. Patient #5 stated no. Personnel #5 stated he (patient) likes to go out to smoke. Personnel #5 was asked if the staff takes the patient out. Personnel #5 stated yes, in a wheelchair. Personnel #5 was asked if he had just come back from smoking then the staff member did not turn on the alarm. Personnel #5 stated correct.

Personnel #2 was told this showed the action plan was not sustained. Personnel #2 stated yes ma'am. We have suspected therapy was not turning on the alarms after therapy. I just called her to talk to her people now.

Based on observation, record review, and interview, the facility failed to ensure ensure that quality improvements are sustained., in that,

the post fall action plan including activated bed/chair alarms was not sustained to provide safety via bed alarms for 3 of 9 high risk patients (Patient #3, #4, and #5) who did not have their bed/chair alarms activated.

Findings

During a tour of the patient care areas on 9/11/2023 at 1:45 PM, Personnel #1, #2, and #5 were present and confirmed the following:

Patient #3 had a High Fall Risk score of 55. She did not have a bed/chair alarm activated.

Patient #4 had a High Fall Risk score of 65. She did not have a bed/chair alarm activated.

Patient #5 had a High Fall Risk score of 50. He did not have a bed/chair alarm activated.

During an interview while touring on 9/11/2023 at 1:45 PM, Personnel #1, #2, and #5 Personnel #5 checked the bed/chair alarm for Patient #3 and confirmed it was not set. Personnel #5 asked Patient #3 if Therapy had just brought her back from therapy. Patient #3 stated yes.

Personnel #5 checked the bed/chair alarm for Patient #4 and confirmed it was not set. Personnel #1 asked Patient #4 if Therapy had just brought her back from therapy. Patient #4 stated yes.

Personnel #5 checked the bed/chair alarm for Patient #5 and confirmed it was not set. Personnel #5 asked Patient #5 if Therapy had just brought him back from therapy. Patient #5 stated no. Personnel #5 stated he (patient) likes to go out to smoke. Personnel #5 was asked if the staff takes the patient out. Personnel #5 stated yes, in a wheelchair. Personnel #5 was asked if he had just come back from smoking then the staff member did not turn on the alarm. Personnel #5 stated correct.

Personnel #2 was told this showed the action plan was not sustained. Personnel #2 stated yes ma'am. We have suspected therapy was not turning on the alarms after therapy. I just called her to talk to her people now.

Based on observation, record review, and interview, the facility failed to ensure the registered nurse supervised and evaluated care for each patient, in that,

3 of 9 high risk patients checked (Patient #3, #4, and #5) did not have their bed/chair alarms activated for safety.

Findings

During a tour of the patient care areas on 9/11/2023 at 1:45 PM, Personnel #1, #2, and #5 were present and confirmed the following:

Patient #3 had a High Fall Risk score of 55. She did not have a bed/chair alarm activated.

Patient #4 had a High Fall Risk score of 65. She did not have a bed/chair alarm activated.

Patient #5 had a High Fall Risk score of 50. He did not have a bed/chair alarm activated.

During an interview while touring on 9/11/2023 at 1:45 PM, Personnel #1, #2, and #5 Personnel #5 checked the bed/chair alarm for Patient #3 and confirmed it was not set. Personnel #5 asked Patient #3 if Therapy had just brought her back from therapy. Patient #3 stated yes.

Personnel #5 checked the bed/chair alarm for Patient #4 and confirmed it was not set. Personnel #1 asked Patient #4 if Therapy had just brought her back from therapy. Patient #4 stated yes.

Personnel #5 checked the bed/chair alarm for Patient #5 and confirmed it was not set. Personnel #5 asked Patient #5 if Therapy had just brought him back from therapy. Patient #5 stated no. Personnel #5 stated he (patient) likes to go out to smoke. Personnel #5 was asked if the staff takes the patient out. Personnel #5 stated yes, in a wheelchair. Personnel #5 was asked if he had just come back from smoking then the staff member did not turn on the alarm. Personnel #5 stated correct.

Personnel #2 was told this showed the action plan was not sustained. Personnel #2 stated yes ma'am. We have suspected therapy was not turning on the alarms after therapy. I just called her to talk to her people now.