HospitalInspections.org

Based on a review of documentation and interview the facility failed to ensure the patient right to receive care in a safe setting, as evidence by failing to ensure and document that a call bell system was within reach of ICU patients.

Findings included:

Facility based policy, entitled "Patient Call Devices" stated in part,
"PROCEDURE
ADMISSION ASSEMENT [sic]
1. The Registered Nurse shall:
o Assure that there is a functional call light at the patient bedside
o Evaluate the patient's ability to use the standard call light
2. If the patient demonstrates appropriate use of the standard call light, the nurse shall:
o Secure the call light proximal to the patient
o Document findings and interventions on the Admission Assessment Data and Nurse Notes
3. If the patient cannot demonstrate appropriate use of the standard call light, the nurse shall:
o Evaluate the patient's ability to use alternative call devices, such as pillow switches (head or foot)
4. If the patient demonstrates appropriate use of the an [sic] alternative call device, the nurse shall:
o Secure the device proximal to patient
o Document findings and interventions on the Nurses Notes and Admission Assessment on the patient charts
5. If the patient cannot demonstrate the ability to use an alternative call device, the nurse shall:
o Develop a plan for patient safety and observation
o Assessment on the patient chart

ONGOING ASSESSMENT AND INTERVENTION:
Minimally every two hours, the staff shall: verify that the patient's call device is easily accessible to him/her....

DOCUMENTATION
Call light in place should be documented every two hours in the appropriate section of the nurse's notes."
Pateint #1 was in the facility from 12//19 to 01/17/20 this patient had a diagnosis of cerebral palsy with impaired motor functions. At times during the their hospital course they were non-verbal, utilizing communication boards, texting on a cell phone, and mouthing words to staff to communicate to them. Staff member #1 verified due to this patient's physical and at times verbal limitations the call light would need to be placed near them for effective use.

Review of the Intensive Care 24-hour record revealed that there was an area titled "Safety and Activity" had an area to document "SR [up arrow symbol] /Call Bell in Reach". The times for documentation are listed as 08, 12, 16, 20, 24, and 04. The boxes have slash so that a check mark can be indicated every 2 hours per policy (such as 0800 and 1000).

Review of this form revealed several dates and times that it was not documented that Pateint # 1's call bell was in reach.
* On 12/28/19 this was not documented at 1600 and 1800.
* On 12/30/19 this was not documented at 1200, 1400, 1600, and 1800.
* On 12/31/19 this was not documented at 1600 or 1800.
* On 01/01/20 this was not documented at 0800, 1000, 1200, 1400, 1600, or 1800.
* On 01/03/20 this was not documented at 1800, 2000, 2200, 2400, 0200, or 0400.

Review of the medial records for current inpatient ICU patients revealed consistent documentation of "SR [up arrow symbol] /Call Bell in Reach" continued to be an issue for 3 of 5 patients. Forms were reviewed from 01/16/20 through 01/22/20.
* Patient #2 was missing this documentation on 01/21/20 at 0800, 1000, 1200, 1400, 1600, or 2000.
* Patient #5 was missing this documentation on 01/22/20 at 0800 and 1000.
* Patient #6 was missing this documentation on 01/19/20 at 1600 and 1800, and 01/20/10 at 0800, 1000, 1200, 1400, 1600, and 1800.

Based on the above findings the facility failed to ensure the safety of patients by ensuring that a call bed system was in easy reach of ICU patients, many of which are on ventilators or have limited mobility.

The above findings were confirmed in an an interview with staff members #1 and 3 on 01/23/20.