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Based on policy review, medical record review, and interview, clinical staff did not ensure a safe environment for Patient #3. This resulted in Patient #3 eloping and being re-hospitalized at another facility.

Findings Include:

Review of Rochester General Hospital Emergency Medicine Unit Structure Standard last approved 11/17/22 revealed objectives include to provide a safe environment for the delivery of patient care across the age continuum, through the prompt detection of emergency conditions and through the prevention of complications. Nursing responsibilities include vital signs and focused assessments: Vital signs are measured at least once per shift or more frequently as indicated by the patient's condition, per nurse's judgement, or ordered by the ED provider.

Review of the triage note dated 01/06/23 at 12:43 PM revealed that according to the children, Patient #3 was confused to time, place, and situation. The son went to check on Patient #3 who was found to be confused. Patient #3 walked out to the ambulance but was not answering questions appropriately.

Review of physician assistant (PA) note dated 01/06/23 at 02:15 PM revealed a neurological exam was performed. Patient #3 is alert to person, place, and month. Has decreased attention and concentration. Is unable to name object and has abnormal comprehension, only responding with days of the week. Patient #3 is unable to perform finger to nose or heel to shin testing due to comprehension difficulties. The National Institute of Health (NIH) Stroke Scale revealed Patient #3 has severe aphasia and responds only with the days of the week.

Review of nursing note dated 01/06/23 at 02:28 PM revealed patient remains confused as too day, date, time, and location. Slow, steady gate.

Review of PA order dated 01/06/23 at 03:39 PM revealed an order for observation status.

Review of physician admission note dated 01/06/23 at 04:19 PM revealed Patient #1 is alert, no dysarthria, but severely aphasic. Patient #3 gives inappropriate answers to questions but follows commands. It is unclear if Patient #3 has insight into illness given confusion and inability to answer questions appropriately. Suspect acute cerebrovascular accident (CVA) and permissive hypertension up to 220/120. We will need to lower blood pressure (BP) to a goal of 220 systolic blood pressure (SBP). Initial SBP is 270. Labetalol 10 mg IV as needed for SBP greater than 220. Activity status is to ambulate ad lib.

Review of physician orders dated 01/06/23 at 04:40 PM reveled to notify the provider if temperature is greater than 38, Systolic Blood Pressure is greater than 220 or less than 110, and Diastolic Blood Pressure is greater than 120.

Review of Vital sign flowsheet dated 01/07/23 revealed at 06:35 AM- BP 251/112, at 06:38 AM- BP 231/112, at 10:41 AM- 196/96, at 03:26 PM- BP 200/90, physician aware.

Review of physician attestation note dated 01/07/23 at 08:24 AM (PA note dated 01/06/23 at 04:29 PM) revealed son states Patient #3 has been confused and altered from baseline. When asked where Patient #3 is, continually repeats name. When asked the date, Patient #3 repeats nonsensical numbers. Visual fields are normal, knows the number of fingers held up and follows commands without difficulty. There is no facial droop or pronator drift. Patient #3 is unable to follow commands for the finger-to -nose test. Patient #3 has a stable gait in the ED. Patient #3 with a new onset stroke like symptoms, suspect acute hypertensive encephalopathy and may have posterior reversible encephalopathy syndrome.

Review of the flowsheet dated 01/07/23 10:44 AM revealed a NIH Stroke scale was performed. When asked the month and age, Patient #3 answers neither question correctly.

Review of Speech, Language, Pathologist note dated 01/07/23 at 11:21 AM revealed Patient #1 presents with moderate receptive and expressive aphasia. Questionable Apraxia complicated by decreased ability to consistently follow 1-step commands, decreased ability to answer yes and no questions, decreased naming objects and automatic speech tasks. When naming objects in the room, Patient #3 would say, "Chery" : and was unaware of the errors. Patient #3 was unable to complete automatic speech tasks and would answer, "Chery" when counting to 10. Patient #3 was inconsistent with following 1-step directions, required a model and was unable to imitate at times. Patient #3 was observed to have spontaneous speech such as, "I want to go home" and "I am tired." Follows one step commands without difficulty. Auditory Comprehension- Yes/No Questions: Exceptions to within functional limits. Basic Questions: Impaired. Commands: Exceptions to within functional limits. One Step basic commands: Impaired. Complex Information: Impaired. Effective Techniques: Extra processing time.

Review of physician note dated 01/07/23 at 02:01 PM revealed left MCA ischemic stroke, intracranial vascular disease, and hyperlipidemia. Allow for permissive hypertension and treat only blood pressure greater than 220/120 mm HG with as needed labetalol or hydralazine.

Review of physician note dated 01/07/23 at 02:35 PM revealed Patient #3 is alert and oriented x3, power is equal in both upper and lower extremities, speech is clear, ocular movement is symmetric, no focal deformity, with general weakness. Activity status is to ambulate with assistance.

Review of the flowsheet dated 01/07/23 at AM, 03:28 PM revealed a NIH Stroke scale was performed. When asked the month and age, Patient #3 answers neither question correctly. "Blink, one eyes" and "Squeeze hands," only performs one task correctly.

Review of nursing note dated 01/07/23 at 04:48 PM revealed Patient #3 was found to have eloped per security. The physician and son were notified.

Review of significant event note by the physician dated 01/07/23 at 04:56 PM revealed notification by the nurse that Patient #3 had eloped with an IV line. Met with Patient #3 this morning who was alert, oriented, understood that had stroke, and was being treated and monitored closely for other stroke symptoms and high blood pressure. Patient #3 had capacity to understand ongoing medical issue. Patient #3's son was called about the situation, who was upset and was trying to get hold of Patient #3. Security was notified of peripherial IV in place and 911 will be notified per nurses note.

Interview on 03/21/23 at 11:30 AM with staff (A) Clinical Regulatory Compliance verified findings.

Based on policy review, medical record review, document review, and interview, nursing staff did not implement fall prevention measures for Patient #2 in accordance with facility policy.

Findings Include:

Review on 03/22/23 of policy "Falls Prevention and Management," last revised 04/2021 revealed the RN is to assess the inpatient on admission, a minimum of once a day and ongoing when a patient's condition of treatment changes. The Hester Davis fall risk scale is used to evaluate patients 18 and older for fall risk. The RN will implement fall prevention strategies as determined by fall risk score. Nursing staff are to implement universal fall precautions for all patients as driven by the care plan in the electronic health record (EMR). For patients with a score of 15 or above, in addition to universal fall precautions staff are required to remain in arms reach of the patient while toileting or transferring. Additional interventions will be driven from the care plan based on the total fall risk score and risk categories where the patient scored 2 or greater.
Hester Davis fall risk per EMR; High fall risk greater than or equal to 15: Patient will remain as independent as possible, have lower fall risk, have lower injury risk, remain safe from falls and injury. Patient/family will understand fall prevention measures and injury reduction measures and comply with fall program.
1. Patients should have an alarm when out of bed in chair or during transport.
2. Fall alarms should be connected to the call light when possible.
3. Use medium or small zone for built in bed alarms. Low beds should only be left all the way down when patient is left unattended. When transferring from bed, adjust height as appropriate. Handoff communication shift to shift includes review of prevention interventions in place.

Review on 03/22/23 of the medical record for Patient #2 dated 11/09/22-11/18/22 revealed the following:
On 11/09/22:
-At 07:43 AM, Patient #2 arrived at facility and was admitted to Orthopedic service for elective surgery. At 09:20 AM informed consent was signed for a Left knee replacement under general anesthesia.
-At 08:51 AM Nursing Assessment; A Hester Davis Assessment was completed (Fall Risk Assessment Scale) indicating a score of 21 (High Falls Risk). Patient #2 is alert, awake and orientated to date, place, and person. A Universal Falls Assessment was completed with the following interventions: non-skid footwear was intact, patient used wheelchair and walker, hourly rounding done by staff, environment was free of clutter, call light was in reach, bed was in low position, lighting was adequate, and yellow gown was intact (indicates fall risk). Patient #2 was educated to call for assistance and bed/chair alarm was listed as N/A.
-At 11:51 AM Operative Note: Left total knee arthroplasty preformed, no issues identified dressings applied and patient was transferred to PACU (post anesthesia unit) in good condition. Post Op: Activity as tolerated and weight bearing as tolerated. Discharge when safe per physical therapy.
-At 03:08 PM Nursing Note: At 03:26 PM, Patient #2 was transferred to floor 6800.
-At 04:44 PM: Nursing Flowsheet; Plan of Care was reviewed in shift handoff, indicating safety precautions reviewed with interventions to ambulate with assist, initiate falls precautions, fall protocol, and provide and maintain a safe environment.
-At 08:45 PM Provider Note: Called to bedside by Nursing staff. Patient #2 had an unwitnessed fall. Patient #2 was attempting to transfer from the Geri chair to the bed when legs slowly slipped out from underneath.
On 11/11/22:
-At 07:57 AM Nursing Note: During shift change, Patient #2 was heard calling for help between 07:00 PM and 07:30 PM while the writer was receiving report on patients. Patient #2 was found lying on the floor by the recliner supine (on back). Patient #2's compression devices were on. Patient #2's right foot was under the recliner. Using the Hoyer lift, Patient #2 was repositioned back in bed. There was a chair alarm pad in the seat of the recliner, but it was not attached to the alarm device. Patient #2 stated should have listened and not try to get up without assistance. Doctors responded at bedside and examined Patient #2, who stated slid out of the chair onto buttocks. There is no documentation indicating the date/time of Patient #2's fall or that this note was a late entry.

Interview on 03/22/23 at 11:00 AM with Staff (II), RN 6800 revealed Patient #2 came up to the unit around 05:00 PM, was alert, orientated, and answering all questions appropriately. Staff (EE), PCT, had Patient #2 up sitting in her chair with a chair alarm pad on the chair. However, Staff (II) was not aware that the chair alarm was not functioning. Staff (EE) stated there was no box for the chair pad (which is part of the alarm to make the alarm sound) and was going to look for one to attach to the pad. Staff (II) stated that prior to leaving the room, Patient #2 had the call bell. Shortly after Patient #2 came up to the floor, the shift ended, and report was given to Staff (DD) RN, who was the oncoming nurse. Staff (II) discovered the next day that Patient #2 had suffered a fall.

Review of document "6800 Indirect PCT checklist (for Staff GG)" indicates staff are to round daily on every room to ensure blood pressure and stethoscope at each bedside, chair alarm present and working, gloves stacked in each room, suction canister set up and suction working at each bedside, isolation caddies stocked, check in with charge/nurse manager to see if any other pertinent needs for the day. No evidence was found to indicate additional staff have been educated to complete this duty or an alternate plan has been made in the event of Staff (GG's) absence to ensure chair alarms are functional.

Review of personal files, facility documentation, and staff training revealed no evidence that the 6800 Nursing Staff, including PCT's and/or other nursing staff on different units were re-educated on fall precautions and/or ensuing alarms are available and functioning on the unit, following Patient #2's fall event on 11/09/22.

Interview on 03/22/23 at 10:00 AM with Staff (R), RN Nurse Manager 6800, revealed only one staff member (Staff GG- PCT) from the 6800 unit has been educated on the "6800 Indirect PCT Checklist" and assigned the task of ensuring chair alarms are present and working. No policy for the checklist was found.

Based on policy review, medical record review, policy review and interview nursing staff did not document the fall event for Patient #2 timely and accurately per facility policy.

Findings Include:

Review on 03/22/23 of policy "Medical Records Procedure," last revised 09/2022 revealed timely and comprehensive documents will ensure complete and accurate portrayal of the patient's care. All entries must be legible, completed, dated, and timed, and authenticated in written or electronic form by the person responsible for providing or evaluating a service. For corrections made at a later date record "see addendum dated" at the site of original entry then document an addendum with current date, time, entry, and signature.

Review on 03/22/23 of the medical record for Patient #2 revealed the following:
-On 11/09/22 at 08:45 PM, the Provider Note indicates Patient #2 had an unwitnessed fall. Patient #2 was attempting to transfer from the Geri chair to the bed when legs slowly slipped out from underneath. Patient #2 landed on tailbone.
-On 11/11/22 at 07:57 AM Nursing Note indicates: During shift change, Patient #2 was heard calling for help between 07:00 PM and 07:30 PM while the writer was receiving report on patients. Patient #2 was found lying on the floor by the recliner supine (on back). Patient #2's compression devices were on. Patient #2's right foot was under the recliner. Using the Hoyer lift, Patient #2 was repositioned back in bed. There was a chair alarm pad in the seat of the recliner, but it was not attached to the alarm device. Patient #2 stated should have listened and not try to get up without assistance. Doctors responded at bedside, examined Patient #2, who stated slid out of the chair onto buttocks. They determined that the ankle was not broken and would monitor it. Ice and pain medication was provided for the duration of the shift. There is no documentation indicating the date/time of Patient #2's fall or that this note was a late entry.

Interview on 03/20/23 at 01:00 PM with Staff (G), RN, Clinical Regulatory Compliance, verified this finding.