HospitalInspections.org

According to record review and staff interview, the facility failed to provide a safe environment while Patient #20 was receiving care in the Emergency Department (ED). Patient #20 came to ED with the chief complaints of immediate mechanical fall and other comorbidities which triggered a high-risk fall assessment result. A comprehensive fall prevention intervention should had been implemented including but not limited to placement of bed alarm and transferring the patient to a room that is visible for the staff to closely monitor patient's activity. The facility failed to implement the ED fall prevention interventions for high fall risk patient as stipulated in the hospital Patient Falls Prevention Policy. The hospital has the responsibility to ensure that services are provided in a safe manner in compliance with applicable rules and standards.

The facility failed to ensure that all licensed staff must adhere to the policy and procedure of the hospital as evident by failure of Staff #1 to report the fall incident which was a reportable event according to the hospital Patient Falls prevention policy. Failure to report the incident was also not in compliance with the hospital's Post Fall Care Protocol. The failure to comply resulted to the following:
- Inability of the hospital to assess and analyzed the situation.
- Inability to implement a new fall prevention plan.
- Inability to report to the physician to request revision of patient's treatment plan as indicated
- Avoidance of recurrences of same incident.