HospitalInspections.org

Based on document review, medical record review and staff interview it was determined the facility failed to keep a patient free from harm by ensuring the bed alarm was on for one (1) of ten (10) patients (patient #1). Failure to ensure the bed alarm is set has the potential to affect all patients who are a fall risk.

Findings include:

A review of the hospital policy entitled "Fall Prevention Program," last reviewed 1/20/22, revealed in part: "Until all assessments are complete all patients are treated as high risk for falls ... Upon admission, plan of care for fall prevention will be initiated to include at a minimum: Bed Alarm ..."

A review of patient #1's medical record revealed the patient was found unresponsive on the floor lying perpendicular to the bed with their head in the direction of the foot of the bed on 1/31/22 at 5:15 a.m. following an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was started, and the emergency medical squad (EMS) was called. The patient was transported to the emergency room and expired in the emergency room.

A telephone interview conducted with Registered Nurse #2 on 4/11/22 at 11:00 p.m. revealed the patient's oxygen tubing had come apart in the middle during the fall. The patient was bagged with an ambu bag and there were no secretions noted.

A telephone interview conducted with the Rehab Nurse Technician (RNT) on 4/11/22 at 9:55 p.m. revealed the patient had been incontinent during the night and they had cleaned the patient during rounds. The last time the patient had been incontinent and cleaned was on 1/31/22 at 3:30 p.m. The RNT stated they turned the bed alarm off while cleaning the patient and could not remember if the bed alarm had been turned back on, but the patient did have the call light in reach.

An interview was conducted with the Director of Quality on 4/12/22 at 8:30 a.m. and they agreed with the above findings.

A. Based on document review, medical record review and staff interview it was determined nursing failed to follow their medication administration policy for time sensitive medications for one (1) of ten (10) (patient #1) patient records reviewed. Failure to follow the medication administration policy has the potential to affect all patients and increases the risk of medication errors and adverse events.

Findings include:

A review of the hospital policy entitled "Medication Administration," last reviewed 6/25/21, revealed in part: "Time sensitive medications shall be administered within 30 minutes (before or after) of the prescribed time. Time sensitive medications include the following: Anticonvulsants ... Prior to administering medications ... Confirm the "six right" of medication administration ... Right time (Scanning medication) ..."

A review of patient #1's medical record revealed the patient had an order for Gabapentin three hundred (300) milligrams (mg) five (5) times a day with a start date/time of 1/30/22 at 8:00 p.m. The first dose of the medication was given at 10:26 p.m. The second dose was given at 1:15 a.m., which was two (2) hours and forty-five (45) minutes after the first dose and one (1) hour and thirty (30) minutes early.

A telephone interview conducted with Registered Nurse #2 on 4/11/22 at 11:00 p.m. revealed it was not uncommon for new patients to receive the first dose of medication late. When asked about the second dose being given two (2) hours and forty-five (45) minutes after the first dose, they stated they used their nursing judgement and tried to give the medication as close to possible when it was due.

An interview conducted with the Director of Quality on 4/12/22 at 8:30 a.m. revealed they agreed the medication administration policy was not followed and the second dose of Gabapentin was given too early.

B. Based on document review, medical record review and staff interview it was determined nursing failed to follow the fall prevention policy by ensuring the bed alarm was set for one (1) of ten (10) patients (patient #1). This failure has the potential to affect all patients who are at risk of falls.

Findings include:

A review of the hospital policy entitled "Fall Prevention Program," last reviewed 1/20/22, revealed in part: "Until all assessments are complete all patients are treated as high risk for falls ... Upon admission, plan of care for fall prevention will be initiated to include at a minimum: Bed Alarm ..."

A review of patient #1's medical record revealed the patient was found unresponsive on the floor beside of the bed on 1/31/22 at 5:15 a.m. following an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was started, and the emergency medical squad (EMS) was called. The patient was transported to the emergency room and expired in the emergency room.

A telephone interview conducted with the Rehab Nurse Technician (RNT) on 4/11/22 at 9:55 p.m. revealed the patient had been incontinent during the night and they had cleaned the patient during rounds. The last time the patient had been incontinent and cleaned was on 1/31/22 at 3:30 a.m. The RNT stated they turned the bed alarm off while cleaning the patient and could not remember if the bed alarm had been turned back on, but the patient did have the call light.

An interview was conducted on 4/12/22 at 8:30 a.m. with the Director of Quality and they agreed with the above findings.