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Based on review of documents, review of the medical record for patient #1 and staff interviews it was revealed the facility failed to ensure care was rendered in a safe setting. Facility failed to ensure equipment with malfunctioning alarms were immediately removed from service and repaired prior to further use. (see tag 144).


A. An IJ to Patient Rights (Care in a Safe Setting) and Nursing Services (failure to follow policy and procedures) was called on 2/23/21 at 9:00 a.m. because the facility failed to ensure Nursing Services followed the hospital's policies and procedure by ensuring equipment with malfunctioning alarms were immediately removed from service and repaired prior to further use.

B. Harm or Potential Harm: An adverse outcome occurred due to the patient fell out of her bed and the bed alarm did not alarm. The patient was found in the floor with a head injury. She was transferred to a local hospital where she later died.

C. Immediacy: The facility must ensure equipment with malfunctioning alarms are removed from service.

D. A remedial plan of correction was received and sent to the State agency Program Director. It was accepted by the surveyor and the facility abated the IJ on 2/23/21 at 2:40 p.m. by completing re-education of removing malfunctioning equipment from patient use, re-education of the policy titled "Alarm Management", International Shared Services was contacted to have clinical engineers to complete patient bed inspections, and all patient bed malfunctions will be reported tagged immediately and reported to operations every morning.

Based on review of documents, review of the medical record for patient #1 and staff interviews it was revealed the facility failed to ensure nursing care services was provided as per hospital policy and procedures. Nursing failed to ensure equipment with malfunctioning alarms were immediately removed from service and repaired prior to further use. Nursing failed to ensure fall risk assessments were completed as per policy. (see Tag 398).


A. An IJ to Patient Rights (Care in a Safe Setting) and Nursing Services (failure to follow policy and procedures) was called on 2/23/21 at 9:00 a.m. because the facility failed to ensure Nursing Services followed the hospital's policies and procedure by ensuring equipment with malfunctioning alarms were immediately removed from service and repaired prior to further use.

B. Harm or Potential Harm: An adverse outcome occurred due to the patient fell out of her bed and the bed alarm did not alarm. The patient was found in the floor with a head injury. She was transferred to a local hospital where she later died.

C. Immediacy: The facility must ensure equipment with malfunctioning alarms are removed from service.

D. A remedial plan of correction was received and sent to the State agency Program Director. It was accepted by the surveyor and the facility abated the IJ on 2/23/21 at 2:40 p.m. by completing re-education of removing malfunctioning equipment from patient use, re-education of the policy titled "Alarm Management", International Shared Services was contacted to have clinical engineers to complete patient bed inspections, and all patient bed malfunctions will be reported tagged immediately and reported to operations every morning.

Based on document review and review of the medical record for patient #1 and it was revealed the facility failed to provided care in a safe setting. The facility failed to ensure equipment with malfunctioning alarms were immediately removed from service and repaired prior to further use. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was admitted on 1/22/21 for left side cerebrovascular accident with right hemiparesis. An order for fall precaution was received due to the patient having a Morse score of fifty (50). Nursing documentation for 2/6/21 at 1:40 a.m. revealed nursing staff went in the patient's room to assist with toileting and the staff located patient #1 on the floor with a head wound. Registered Nurse (RN) #2 documented the bed alarm was showing active and flashing a low weight light after the fall. Per nursing documentation, the bed alarm did not alarm when the patient fell out of bed. Patient #1 was transferred to a local hospital for evaluation on 2/6/21 and later died.

2. A review of the policy titled "Alarm Management, effective date 11/28/2017, stated in part: "Equipment with malfunctioning alarms will be immediately removed from service and repaired prior to further use."

3. A review of the root cause analysis (RCA) investigation interviews revealed RN #2 stated, "When I took report from day shift nurse, at the beginning of the shift the nurse made mention that they had problems with the bed on day shift. That nurse and the Nurse Manager got the patient out of bed and had to re-zero and re-weigh the patient. They felt the bed was working properly again."

4. An interview was conducted with the Director of Maintenance on 2/22/21 at 3:20 p.m. When asked if maintenance had been informed a bed alarm was not working properly on 2/5/21, he stated they were not notified until 2/8/21, the day the bed was taken out of service. He stated they did not receive any notification of any problems with the bed alarms. He stated their contract group who ensures all new equipment is working properly is at the facility weekly. He stated they have two (2) maintenance personnel at the facility, and they are on call twenty-four (24) hours a day seven (7) days a week. He stated maintenance on the bed was completed 4/13/20 and is due on 4/2021. He stated if a work order is received, then they check the problem or equipment immediately.

5. An interview was conducted with the Director of Quality on 2/22/21 at 3:45 p.m. When asked if there were any other beds on the unit for patient use, she stated, "Yes." She stated after the patient left the facility the patient's bed had to be properly cleaned and guidelines followed due to the patient being positive for COVID.

6. A telephone interview was conducted with RN #2 on 2/23/21 at 8:43 a.m. When asked about patient #1, she stated she did remember the incident because she was her patient. She stated she was told in report the nurse and Nurse Manager from day shift on 2/5/21 had to remove the patient from her bed due to the weight on the bed was off. She was informed they re-zeroed the bed, and they felt the bed was working again. At 1:15 a.m. on 2/6/21 patient #1 was in her bed asleep. She stated at approximately 1:35 a.m. on 2/6/21 they went in the room; she was checking on patient #2 and the nurse tech was checking on patient #1. She stated, "At that time patient #1 was located in the floor beside her bed, she was lying sideways. She stated the bed alarm was still set to the on position and the bed alarm did not go off when the patient fell out of bed. A rapid response was called, the physician was notified, and the patient was transferred to a local hospital. She stated on Sunday 2/6/21 when she arrived to work for her 6:00 p.m. to 6:00 a.m. shift, another patient was in the same bed. She stated the bed alarm was not set when she arrived to start her shift and she could not get the bed alarm to set. She stated she placed a posey pad bed alarm on the bed since the bed was not working properly.

7. A telephone interview was conducted with nurse tech #2 on 2/23/21 at 10:06 a.m. She stated, "We went to provide personal care to patient #1 but I did not initially see her. Patient #1 was face down in a huge puddle of blood." She stated the bed alarm was on but did not alarm. She stated they also had a baby monitor in the room and at the nurse's station. They did not hear anything. She stated after the fall there was very little response from the patient. She had a large gash and lump on her forehead. She stated, "It is so sad that the patient died. I could tell the patient was hurt bad. The bed was defective, and we are having a lot of problems with the bed alarms. The indicators are not working appropriately on the beds."

8. A telephone interview was conducted with RN #1 on 2/23/21 at 10:46 a.m. When asked if they were having problems with the patient's bed on day shift, RN #1 stated, "No." When asked why the patient was removed from the bed and re-weighed, she stated, "We weren't having any problems, we only weighed to ensure accurate for weight. We re-zeroed the bed and set the alarm. It was time for her daily weight." When asked if they are required to weigh patients daily, she stated, "Yes."

9. A telephone interview was conducted with RN #3 on 2/23/21 at 1:31 p.m. When asked about the incident with patient #1, she stated the bed alarm did not go off when the patient fell. She noted there was a baby monitor in the room for patient #2. She stated, "I feel the alarm would have been picked up by the baby monitor, which was in the room, if the bed had alarmed." She stated she was not informed of a problem with the patient's bed on day shift.

10. A telephone interview was conducted with nurse tech #4 on 2/23/21 at 3:53 p.m. Nurse tech #4 stated, "When I entered the room the patient was on the floor, the bed alarm said bed exit with no alarm sounding." When asked if they were informed if a bed alarm did not work, they are to remove the bed from services, nurse tech #4 stated, "No." They were told if a bed alarm did not work to use a posey pad bed alarm.

11. A telephone interview was conducted with the Chief Nursing Officer on 2/24/21 at 1:25 p.m. When asked if they require all patients to be weighed daily and bed reset, she stated, "No." They do not require the patients to be re-weighed daily. She concurred the nursing staff failed to follow policy for removal of equipment with malfunctioning alarms and to immediately remove from service until repaired for further use.

Based on a review of the medical record for patient #1, document review and staff interviews it was revealed nursing failed to follow the facility's policies and procedures. Nursing failed to ensure equipment with malfunctioning alarms were immediately removed from service and repaired prior to further use. Nursing failed to ensure fall risk assessments were completed as per policy. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was admitted on 1/22/21 for left side cerebrovascular accident with right hemiparesis, an order for fall precaution was received due to the patient had a Morse score of fifty (50). Patient #1 was COVID positive and under COVID precautions. Nursing documentation for 2/6/21 at 1:40 a.m. revealed nursing staff went in the patient's room to assist with toileting, the staff located patient #1 on the floor, with a head wound. Registered Nurse (RN) #2 documented the bed alarm was showing active and flashing a low weight light after the fall. Per nursing documentation, the bed alarm did not alarm when the patient fell out of bed. Further review of the medical record revealed nursing failed to complete fall risk assessments at least weekly as per policy, an initial fall risk assessment was completed on 1/22/21 and a post fall risk was completed on 2/6/21, no other fall risk assessments were documented in the medical record. Patient #1 was transferred to a local Hospital for evaluation on 2/6/21 and later died.

2. A review of the policy titled "Alarm Management, effective date 11/28/2017, stated in part: "Equipment with malfunctioning alarms will be immediately removed from service and repaired prior to further use."

3. A review of the policy titled "Fall Prevention Program, effective date 11/18/2020, stated in part: "Frequency of Assessment/Reassessment, Patients should be assessed for risk of falling; 1. On admission to the hospital. 2. On any transfer etc. 3. Following any change of status. 4. Following a fall. 5. Weekly at a minimum."

4. A review of the root cause analysis (RCA) investigation interviews revealed RN #2 stated, "When I took report from day shift nurse, at the beginning of the shift the nurse made mention that they had problems with the bed on day shift. That nurse and the Nurse Manager got the patient out of bed and had to re-zero and re-weigh the patient. They felt the bed was working properly again."

5. An interview was conducted with the Director of Maintenance on 2/22/21 at 3:20 p.m. When asked if maintenance had been informed a bed alarm was not working properly on 2/5/21, he stated they were not notified until 2/8/21, the day the bed was taken out of service. He stated they did not receive any notification of any problems with the bed alarms. He stated their contract group who ensures all new equipment is working properly is at the facility weekly. He stated they have two (2) maintenance personnel at the facility, and they are on call twenty-four (24) hours a day seven (7) days a week. He stated maintenance on the bed was completed 4/13/20 and is due on 4/2021. He stated if a work order is received, then they check the problem or equipment immediately.

6. An interview was conducted with the Director of Quality on 2/22/21 at 3:45 p.m. When asked if there were any other beds on the unit for patient use, she stated, "Yes." She stated after the patient left the facility the patient's bed had to be properly cleaned and guidelines followed due to the patient being positive for COVID.

7. A telephone interview was conducted with RN #2 on 2/23/21 at 8:43 a.m. When asked about patient #1, she stated she did remember the incident because she was her patient. She stated she was told in report the nurse and Nurse Manager from day shift on 2/5/21 had to remove the patient from her bed due to the weight on the bed was off. She was informed they re-zeroed the bed, and they felt the bed was working again. At 1:15 a.m. on 2/6/21 patient #1 was in her bed asleep. She stated at approximately 1:35 a.m. on 2/6/21 they went in the room; she was checking on patient #2 and the nurse tech was checking on patient #1. She stated, "At that time patient #1 was located in the floor beside her bed, she was lying sideways. She stated the bed alarm was still set to the on position and the bed alarm did not go off when the patient fell out of bed. A rapid response was called, the physician was notified, and the patient was transferred to a local hospital. She stated on Sunday 2/6/21 when she arrived to work for her 6:00 p.m. to 6:00 a.m. shift, another patient was in the same bed. She stated the bed alarm was not set when she arrived to start her shift and she could not get the bed alarm to set. She stated she placed a posey pad bed alarm on the bed since the bed was not working properly.

8. A telephone interview was conducted with nurse tech #2 on 2/23/21 at 10:06 a.m. She stated, "We went to provide personal care to patient #1 but I did not initially see her. Patient #1 was face down in a huge puddle of blood." She stated the bed alarm was on but did not alarm. She stated they also had a baby monitor in the room and at the nurse's station. They did not hear anything. She stated after the fall there was very little response from the patient. She had a large gash and lump on her forehead. She stated, "It is so sad that the patient died. I could tell the patient was hurt bad. The bed was defective, and we are having a lot of problems with the bed alarms. The indicators are not working appropriately on the beds."

9. A telephone interview was conducted with RN #1 on 2/23/21 at 10:46 a.m. When asked if they were having problems with the patient's bed on day shift RN #1 stated, "No." When asked why the patient was removed from the bed and re-weighed, she stated, "We weren't having any problems, we only weighed to ensure accurate for weight. We re-zeroed the bed and set the alarm. It was time for her daily weight." When asked if they are required to weigh patients daily, she stated, "Yes."

10. A telephone interview was conducted with RN #3 on 2/23/21 at 1:31 p.m. When asked about the incident with patient #1, she stated the bed alarm did not go off when the patient fell. She noted there was a baby monitor in the room for patient #2. She stated, "I feel the alarm would have been picked up by the baby monitor, which was in the room, if the bed had alarmed." She stated she was not informed of a problem with the patient's bed on day shift.

11. A telephone interview was conducted with nurse tech #4 on 2/23/21 at 3:53 p.m. Nurse tech #4 stated, "When I entered the room the patient was on the floor, the bed alarm said bed exit with no alarm sounding." When asked if they were informed if a bed alarm did not work, they are to remove the bed from services, nurse tech #4 stated, "No." They were told if a bed alarm did not work to use a posey pad bed alarm.

12. A telephone interview was conducted with the Chief Nursing Officer on 2/24/21 at 1:25 p.m. When asked if they require all patients to be weighed daily and bed reset, she stated, "No." They do not require the patients to be re-weighed daily. She concurred the nursing staff failed to follow policy for removal of equipment with malfunctioning alarms and to immediately remove from service until repaired for further use.