Audit of Changi healthcare facility finds 2 patient falls in 6 weeks, says they were 'preventable'

A monthly audit at a Singapore healthcare facility found several issues, including patients falling from beds and wheelchairs and improperly-labelled supplies.

The findings of the audit, which took place on Sep. 17, were circulated in a staff directive which was viewed by Mothership.

The facility itself is Transitional Care Facility @ East (TCF@East), a step-down care environment for patients awaiting long-term care or home placement.

In response to Mothership's queries, HHOM Pte Ltd, a subsidiary of MOH Holdings which conducted the audit, said that they have since followed up with the operator on areas of improvement.

Fall incidents

The directive made explicit mention of two fall incidents which took place in August and September this year.

The first patient was reportedly seated in a wheelchair without a safety belt. They attempted to stand, tripped over the footrest, and fell.

The second patient reportedly fell out of his bed while the nurse-in-charge was occupied and the junior staff was on break.

He was later found on the floor.

Both were listed as "preventable falls" concerning "high-risk" patients, according to the directive.

In the second case, it was noted that "supervision was limited at the time" as both staff members were otherwise occupied.

Other issues

The directive also alleged that other issues had been found, including improperly-stored and labelled items, dustbins that went unemptied, and expired medication.

Patients were also found sleeping without their bed rails raised for safety, according to the message.

A staff member, who spoke to Mothership on condition of anonymity, said that they had observed issues with patient safety over their time working there.

Earlier in May, it was reported that the same facility issued a directive to its nurses, requiring them to give advance notice when applying for medical leave or risk having their salary deducted.

It later claimed it was a misunderstanding.

Follow-up

In its Oct. 7 reply to Mothership, HHOM confirmed that it had identified "some areas of improvement relating to the storage and labelling of supplies", although no expired medication was found.

It also confirmed that a bed rail was observed to have been left down while a patient was sleeping.

As to the fall incidents, HHOM said it takes such reports "seriously", and has since followed up with the facility on areas of improvement.

"HHOM will continue to work closely with TCF operators and monitor their practices to ensure that patient safety and quality of care remain a priority," a spokesperson said.