HospitalInspections.org

Based on medical record review and interview, the facility failed to ensure a safe environment was maintained for one (#1) of nine patients reviewed:

The findings included:

Patient #1 was admitted to the facility on April 26, 2009, with a diagnosis of Altered Level of Consciousness. Medical record review of the nursing notes and care plan revealed the patient was identified as a fall risk on April 27, 2009. Medical record review of the nursing notes and care plan dated April 27, through May 1, 2009, revealed the patient was to have a bed alarm in place at all times while in bed. Medical record review of a nursing note dated April 30, 2009, at 1:50 a.m., revealed "Tech found pt (patient) on the floor. Pt stated that...tried to get up to use the bedside commode...The pt stated that...hit...head and it was hurting...There was no visible injury...Pt went for stat (immediate) CT of the head (type of x-ray imaging) and neuro (neurological) checks were done every hour...Bed alarm is on." Medical record review of the CT scan dated April 30, 2009, revealed "No acute abnormality...Soft tissue swelling overlies the posterior occipital region (back of the head) without underlying fracture..." Medical record review of the Discharge Summary dated May 2, 2009, revealed the patient experienced a fall while in the hospital and had bruising and soft tissue swelling to the base of the skull and neck from the fall.

Interview with the Nurse Manager on June 2, 2010, at 10:15 a.m., in an Administration Conference Room, confirmed the patient was a high risk for falls and required a bed alarm while in bed. Continued interview revealed the alarm had not been turned on after staff assisted the patient to bed on April 30, 2009, and the patient got out of bed, unassisted, and fell, resulting in bruising to the back of the head and neck.

c/o #25766

Based on medical record review and interview, the facility failed to ensure the care plan was implemented for one (#1) of nine patients reviewed:

The findings included:

Patient #1 was admitted to the facility on April 26, 2009, with a diagnosis of Altered Level of Consciousness. Medical record review of the nursing notes and care plan revealed the patient was identified as a fall risk on April 27, 2009. Medical record review of the care plan dated April 27, through May 1, 2009, revealed, "...Fall Prevention...Patient can expect a safe environment and surveillance to avoid injury...Use Bed Alarm..." Medical record review of the nursing notes dated April 27, through May 1, 2009, revealed the patient was to have a bed alarm in place at all times while in bed. Medical record review of a nursing note dated April 30, 2009, at 1:50 a.m., revealed "Tech found pt (patient) on the floor. Pt stated that...tried to get up to use the bedside commode...The pt stated that...hit...head and it was hurting...There was no visible injury..."

Interview with the Nurse Manager on June 2, 2010, at 10:15 a.m., in an Administration Conference Room, confirmed the patient's care plan included a bed alarm while in bed. Continued interview revealed the alarm had not been turned on after staff assisted the patient to bed on April 30, 2009, and the patient got out of bed, unassisted, and fell, resulting in bruising to the back of the head and neck.

c/o #25766