Mrs. P is a white female 93-year-old admitted to your facility. She has had Alzheimer's for around 7 years and has being cared for at home by her husband and daughter. Diabetes, hypertension, osteoarthritis, depression, and a history of falls are among her other prior medical issues. Her family has finding it more difficult to care for her at home in recent months as her agitation and sleeplessness have worsened.

Mrs. P has been at your facility for three days and has only slept three hours per night. She is constantly restless and agitated, and she frequently calls out for her spouse. She is continually wanting to get out of her chair or bed. Mrs. P was discovered on the floor by employees at 8 p.m., probably having fallen onto her buttocks; no injuries were discovered. Mrs. P was helped to bed for the night. Her waist was restrained, and all four side rails were erect.

Mrs. P was discovered unconscious on the floor later that evening. Her underwear was filthy, and she continued to scream for her husband. She was found to be unharmed as a result of the fall. The nurse acquired a sedative order from the doctor and administered Ativan 1.0 mg at 1 a.m. She was returned to her bed and eventually fell asleep for the night.

 

Describe the current issue and the activities of the employees, as well as any alternative measures that may have been taken.

Discuss the situation and videos in relation to omission and commission mistakes. This occurrence is deemed an error of omission or conduct. Explain why.

What steps may be made to avoid such incidents?

What initiatives (policy and procedures) can HCA do to guarantee patient safety and quality of care?