HospitalInspections.org

Based on record review, physician and staff interview, the Emergency Department (ED)staff failed to implement appropriate measures to ensure the safety for one of one applicable Patient's brought to the ED by ambulance in an intoxicated state in March 2010.

The findings are as follow:

Review of the Emergency Medical Services (EMS) Trip Report dated 03/15/10 indicated the Patient was transported to the ED by ambulance after allegedly stumbling into a parked car and falling into a gutter. The EMS report indicated the Patient was uncooperative after being aroused by the EMS technicians. The EMS report indicated there were no apparent injuries.

Review of the Triage ED Record dated 03/15/10 at 2 AM indicated the Patient was unresponsive however the Patient withdrew from pain. The Patient did not appear to be in any apparent distress. The Patient's respirations were even and unlabored. The Patient's vital signs were recorded at 2:07 AM as a blood pressure of 126/87, heart rate of 84 beats per minute and respirations 14 breaths per minute with an oxygen saturation level of 93% on room air (normal range for most patients is between 98% to 100%). The Patient's behavior was drowsy and the smell of alcohol was detected from the Patient's breath. The Patient's Glasgow Coma Scale was recorded as 10. A Glasgow Coma Scale (GCS) consists of measuring three components for the patients level of consciousness and severity of injury: eye opening, verbal responsiveness and motor response. The GCS can range from a low score of 3 to high score of 15 depending on the patients alertness and response to stimuli.The Patient was identified as at risk for falls.

Continued review of the ED Nursing Assessment indicated the Patient was not able to provide a history secondary to an obtunded state (decreased level of alertness).

Registered Nurse #1 was interviewed in person on 04/01/10 at 10:20 AM. Registered Nurse #1 was the clinical nurse manager at the time of the Patient's evaluation in the ED. Registered Nurse #1 said the Patient was placed in the corridor in front of the nurses station on a stretcher because the Patient was an automatic fall risk secondary to the Patient's intoxication. Registered Nurse #1 said the Patient was loud, belligerent and yelling at times. Registered Nurse #1 said the Patient did not make any attempts to get up from the stretcher. Registered Nurse #1 said the Patient was issued a pulse oximetry sensor and the Patient's saturation levels were okay. Registered Nurse #1 said if the the Patient had been uncooperative or moved about to cause harm the Patient would have been assigned to a sitter. Registered Nurse #1 said the resources were here which often is a one to one sitter or a runner can be used but the Patient did not require a one to one sitter.

Review of the Hospital's Policy for the Care of the Intoxicated Patient indicated alcohol and drug use impair an individuals judgment and interfere with patient's ability to provide a complete and accurate history, therefore even if the cause of admission to the ED is known, assessment priorities should remain the same: airway, breathing, circulation and disability. The Policy indicated impairment may also mask symptoms of other life threatening illnesses or injury, so every effort should be made to facilitate rapid head to toe assessment of these patients. The Policy indicated that every effort should be made to facilitate rapid placement of the patient into an ED patient room, for the purpose of early evaluation and determination of acuity. The Policy indicated the Patient's Glasgow Coma Scale, Level of Orientation and pupil assessment should be documented. The Policy indicated patients with chronic ETOH (alcohol) use are at risk for a subdural hematoma and head injuries related to fights, falls and trauma therefore the Glasgow Coma Scale should be obtained with each vital sign. The Policy indicated the nurse assessment should assess vital signs, oxygen saturation levels and pain scale. The Policy indicated the nurse assessment should include palpating the patients head and neck for tenderness, deformity and trauma. The Policy indicated if there were any signs or suspicion of head injury/trauma a cervical collar should be issued and documented as applied in the patient record.

Registered Nurse #1 said the Patient did not arrive to the ED in a cervical collar.

Continued review indicated, the Patient's Glasgow Coma Scale at 2:20 AM was recorded as having decreased with a score of 8 and the Patient's oxygen saturation level was recorded as 97%. There was no recorded blood pressure or heart rate. The Nursing Assessment documented at 2:20 AM indicated the Patient did not appear to be in any distress. The Nursing Assessment indicated the Patient's behavior was drowsy and speech slurred. The Patient's level of consciousness was awake. The Patient moved all extremities. The Nursing Assessment indicated the Patient had a bruise to the left shoulder and left elbow which was red and green (an older bruise). The Patient was not oriented to (person, place or time).

Registered Nurse #4 was interviewed by telephone on 04/05/10 at 3:50 PM. Registered Nurse #4 said she was assigned to the Patient. Registered Nurse #4 said the Patient was heavily intoxicated, responding only to loud stimulation. Registered Nurse #4 said the Patient arrived to the ED wearing boxer shorts because Emergency Medical Technicians (EMT's) removed the Patient's wet clothing.

The Physician's Assistant (PA) was interviewed by telephone on 04/06/10 at 2 PM. The PA said the Patient was cold and wet on arrival. The PA said no one had a clear idea of what happened to the Patient prior to arrival. The PA said the staff paid close attention to the Patient. The PA said the Patient was intentionally placed in the hallway for close observation at the nurses station. The PA said the hallway was the most appropriate place for the Patient for safety reasons. The PA who initially examined the Patient, said the Patient's head had no signs of trauma. The PA said the Patient's head was visually examined. The PA did not check for tenderness on the Patient's head. The PA said the Patient had attempted to get up once before the fall. The PA then clarified the response by saying the Patient had attempted to sit up on the stretcher but then laid back down.

Review of the PA's Examination documentation dated 03/15/01 at 2:27 AM indicated the Patient was lethargic, listless and non-diaphoretic. The PA indicated the Patient's head and neck was negative for signs of injury or deformity, abrasions, battle signs, contusion, or ecchymosis. The Patient's pupils were equal, round and reactive to light. There was no epistaxis (nose bleeding), or nasal discharge. The PA indicated the Patient's neck was normal and the cervical spine appeared normal with no vertebral tenderness, pain or pain on movement. The PA indicated the Patient did not display any signs of respiratory distress. The PA indicated in the Neurological examination the following: the Patient's orientation, mentation, cranial nerves, cerebellar function and motor reflexes were not able to be tested because the Patient was clinically intoxicated.

Review of the Nursing documentation indicated at 2:30 AM, the Patient's Glasgow Coma Score elevated to a score of 12.

Review of the Nursing Assessment documentation at 3:30 AM indicated the Patient attempted to get out of bed and fell to the floor unwitnessed. The Patient was found to be in a prone position. The Patient denied having any pain and awake, alert and oriented to person. The Patient moved all extremities. The Nursing Assessment indicated the Patient sustained a laceration to the forehead.

Registered Nurse #4 said she hung the clothing on an intravenous poll and the poll was positioned near the Patient. Registered Nurse #4 said the Patient may have tried to reach for the soaked clothing and then fell to the floor. Registered Nurse #4 said the Patient was placed in the hallway in front of the nurses station. Registered Nurse #4 said two patient care technicians and Registered Nurse (#2) were the first to respond to the Patient on the floor. Registered Nurse #4 said there were staff at the nurses station but the Patient's fall was unwitnessed.

At 3:52 AM, the Patient's GCS post-fall was recorded as 14.

Registered Nurse #2 was interviewed in person on 04/01/10 at 2:30 PM. Registered Nurse #2 was identified by Registered Nurse #1 as the first responder to the Patient's fall. Registered Nurse #2 was attending to another patient when the Patient fell. Registered Nurse #2 said upon arrival the Patient was trying to stand with the assistance of a patient care attendant and another registered nurse (#4). Registered Nurse #2 said the Patient reported while attempting to get up to leave, the Patient tripped. Registered Nurse #2 did not recall any clothing hanging on an intravenous pole.

Registered Nurse #3 was interviewed in person on 04/01/10 at 3 PM. Registered Nurse #3 reported having no recollection of the Patient. Registered Nurse #3 said for an intoxicated patient, it was important to observe for signs of trauma and place the stretcher in front of the nurses station for close observation or place the patient in front of the psychiatric rooms with a one to one sitter/observer. Registered Nurse #3 said at the nurses station you can usually see the patient starting to stir and the alarm to the pulse oximetry would have sounded.

Review of the Hospital's Policy for Falls Assessment and Prevention in the ED indicated patients at higher risk for falling as a result of a change in condition, confusion, dementia, intoxication or substance abuse will be placed in a room highly visible to the nursing staff or in the hallway, in the event, no room was available around the main desk. If a private room was necessary due to precautions and/or the patient was combative, loud and disruptive or unable to lay quietly, the patient may be issued a bed alarm, if appropriate or provided with a one to one observer to keep the patient safe.

There were no documented safety checks in the Patient's ED Record.

Despite being reported to the Department, that no rooms were available for the Patient. Registered Nurse #1 and the ED Nurse Manager said there were vacant rooms but the practice was to place intoxicated patients, in the corridor, in front of the main station. The Patient fell to the floor sustaining a head injury while placed in front of the nurses station.

Registered Nurse #1, #2, #3 and #4 and the PA said it was the practice of the ED staff to place intoxicated patients in the corridor rather than provide for direct supervision in a patient room. Registered Nurse #1 and #4 were training another patient with the use of crutches, at the far end of the hallway when the Patient fell. No staff reported that the pulse oximetry alarm was heard sounding prior to the Patient's fall. There was no one individual assigned to observe the Patient. The nursing staff said that a bed alarm was not made available in the ED. The nursing staff were unable to clearly identify the individual who initially found the Patient on the floor.

A tour of the ED was made on the day of survey. The ED Nurse Manager accompanied the Surveyor along with the Hospital's Risk Manager. The ED area was confirmed where the Patient was placed at the nurses station by a diagram drawn by Registered Nurse #1 which was given to the Surveyor during interview. The Viewing area for the placement of the Patient at the nursing station was restricted by the placement of a minimum of three flat screened computer monitors. The nurses work stations were restricted from monitoring the Patient by the fact the individual nurses had their backs toward the Patient's stretcher in an effort to access information on the monitor screen. There was no clear evidence that the nursing station provided for optimal view of the patients placed in the corridor.

The nursing staff did not provide the Patient with the opportunity for optimum safety nor was there documentation that sufficient measures were implemented to prevent a fall.

Continued review of the Patient's ED record indicated the Trauma Team was called to further evaluate the Patient. A Head Computerized Tomography taken post-fall indicated the Patient sustained multiple intracranial hematomas, bilateral subdural hematomas and occipital bone fracture. The Patient was admitted to the Intensive Care Unit for further medical management.