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Based on record review and interviews, the hospital failed to prevent the fall of Patient #1 after identifying that he was a high fall risk. This failed practice likely contributed to the death of Patient #1. (see A-145)


Patient #1 is a high fall risk, 72 year old, severely developmentally delayed individual who arrived in the emergency room via stretcher and was admitted on the evening of 09/19/17. The admitting diagnoses were ileus (medical term for lack of movement somewhere in the intestines that leads to a buildup and potential blockage of food material); constipation; nausea and vomiting with abdominal distention. A naso-gastric (NG) tube was inserted in the emergency room on the day of admission and was removed by the patient on 09/20/17. No attempt was made to reinsert the NG tube. Patient assessment report dated 09/20/17, at 02:35 am, identified Patient #1 with a fall score of 70. The form also identified that all patients with a score higher than 45 must be placed on high fall risk precautions.


While in the emergency room, the patient received a CT (Computerized axial Tomography) scan of the abdomen and pelvis which showed "left base consolidation" (a region of the lung tissue filled with fluid), small right (lung) base effusion (buildup of fluid between the layers of the pleura outside the lungs), marked dilatation of the small bowel and a left inguinal hernia (occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles). While Patient #1 was in the emergency room, the POA (Power of Attorney) requested he have a sitter throughout his stay in the hospital due to his high fall risk. The facility did not assign a sitter at any time.


Review of Hospital Fall Record identified that Patient #1 sustained an unobserved fall and was found on the floor in his room at 05:45 am on 09/21/17. The fall resulted in a hematoma (a solid swelling of clotted blood within the tissues) to his head. Progress note dated 09/21/17, revealed that Patient#1 sustained a fall on the morning of 09/21/17 resulting in blunt force trauma to the right front of the temple region of his head. The patient received a CT Scan at 5:54 am which revealed a subdural bleed (bleeding between the brain and its outermost covering) with a right to left midline shift (a shift of the brain past its center line.) Midline shift is often associated with high intracranial pressure (ICP), which can be deadly. (Medical Physiology, Guyton & Hall , 2006.) Patient #1 was moved to the Intensive Care Unit (ICU). Patient #1 received two additional CT scans, one at 12:39 pm and one at 07:00 am on 09/22/17. Both revealed that there was no longer a midline shift and no appreciable difference in the size of the bleed since the first scan.


Review of the discharge summary by his primary care physician indicated:

"Hospital Course: This 72-year-old man was admitted to the [hospital] on the evening of Sept. 19, 2017, after presenting to the emergency room because of recurrent nausea and vomiting, and also abdominal distention and also because he had fallen and injured his head. Unfortunately, I was never called to see him until after moments after he had expired but was admitted the hospitalist group, and was treated initially with NG suction and IV fluid support, although he did pull out the NG I believe. The CT scan of the head did show a small frontal subdural hematoma, which was followed with serial CT scans. He had been improving until suddenly on the morning of his expiration, he vomited up a large amount of coffee-ground material and had aspirated. He quickly expired. Resuscitation efforts with CPR [Cardio Pulmonary Resuscitation] and intubation were not done because he was no code [Do not resuscitate]. He was pronounced [dead] 7:30 am on 09/22/17."

Based on record review and interviews, the hospital failed to prevent the fall of Patient #1 after identifying that he was a high fall risk. This failed practice likely contributed to the fall and subsequent death of Patient #1. The findings are:


A. Record review of the Emergency Department (ED) Nurse Documentation dated 09/19/17 indicated "20:46 Screening: Abuse assessment: No assessment findings of abuse such as: unexplained injuries or bruising, suspicious burns, signs of withdrawal, depression, or fear of others. Assessment for neglect: No signs or indications of neglect noted, such as: exploitation, malnutrition, or poor hygiene. Fall Risk: 0-2 points- Low risk; fall risk bundle not initiated."


B. Record review of the medical records for Patient #1 indicated:

Patient #1 is a high fall risk, 72-year old, severely developmentally delayed individual who arrived in the emergency room via stretcher and was admitted on the evening of 09/19/17. The admitting diagnoses were ileus (medical term for lack of movement somewhere in the intestines that leads to a buildup and potential blockage of food material); constipation; nausea and vomiting with abdominal distention. A naso-gastric (NG) tube was inserted in the emergency room on the day of admission and was removed by Patient #1 on 09/20/17. No attempt was made to reinsert the NG tube. Patient assessment report dated 09/20/17 at 02:35 am identified Patient #1 with a fall score of 70, the form also identified that all patients with a score higher than 45 must be placed on high fall risk precautions.


While in the emergency room, the patient received a CT (computerized axial Tomography) scan of the abdomen and pelvis which showed "left base consolidation" (a region of the lung tissue filled with fluid), small right base effusion (buildup of fluid between the layers of the pleura outside the lungs, marked dilatation of the small bowel and a left inguinal hernia (occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles). While Patient #1 was in the emergency room, the Power of Attorney or POA requested he have a sitter throughout his stay in the hospital due to his high fall risk. The facility did not assign a sitter at any time.


C. Review of Hospital Fall Record identified that patient #1 sustained an unobserved fall and was found on the floor in his room at 05:45 am on 09/21/17. The fall resulted in a hematoma (a solid swelling of clotted blood within the tissues) to his head. Progress note dated 09/21/17, revealed that Patient #1 sustained a fall in the morning of 09/21/17 resulting in blunt force trauma to the right front of the temple region of his head. The patient received a CT Scan at 5:54 am which revealed a subdural bleed (bleeding between the brain and its outermost covering of the brain inside the skull) with a right to left midline shift (a shift of the brain past its center line.) Midline shift is often associated with high intracranial pressure (ICP), which can be deadly. (Medical Physiology, Guyton & Hall, 2006) Patient#1 was moved to the Intensive Care Unit (ICU). Patient#1 received two additional CT scans, one at 12:39 pm and one at 07:52 pm on 09/21/17. Both revealed that there was no longer a midline shift and no appreciable difference in the size of the bleed since the first scan.


D. Record review of the medical record for Patient #1 revealed pictures of injuries after a fall including an egg-sized hematoma (blood clotted in a lump under the skin) on his right forehead. The photos were not dated or timed or signed.


E. Review of the discharge summary detailed the hospital course: Patient#1 admitted to facility on the evening of 09/19/17 for recurrent nausea and vomiting and abdominal distention. He was originally treated with NG suction and IV fluid support although he pulled out the NG tube. After his fall he received a series of CT scans which showed an improving subdural hematoma. On the morning of 09/22/17, he received an x-ray of his abdomen and CT scan of his head, He had been improving until the morning of 09/22/17 at approximately 7:20 am when he vomited a large amount, aspirated the fluid and quickly expired. He was not intubated and CPR was not started due to DNR (do not resuscitate orders). He was pronounced dead at 07:30 am in the facility.


F. Record review of the hospital's electronic medical record on admission to inpatient on 09/20/17 of Patient #1's fall risk assessment indicated he was calculated to have a risk score of 100 points. Any number greater than 45 points was considered high risk for falls. The Morse Fall Risk Assessment Tool was used by the hospital to objectively measure Patient #1's potential risk of a fall. The protocol considers history of falls, secondary diagnoses such as pain, infection, etc., use of an ambulatory aid, intravenous access, gait, and mental status. Patient #1 was scored at 100 points out of a possible 140 points on the scale. Patient #1 was seen in the ED on 09/19/17 for nausea and assessment of chronic bowel problem. He was admitted to the medical/surgical unit early in the morning of 09/20/17.


G. Record review of the nursing notes identified Patient #1 fell on the morning of 09/21/17 at approximately 5:30 am.


H. Record review of the hospital's undated fall protocol for Patient #1 indicated the hospital considered the use of a sitter (a staff member who stays with the patient in order to prevent falls), optional. The use of a sitter is a standard nursing practice of preventing falls in high risk patients. The fall protocol did not spell out what number on the risk scale would require the assignment of a sitter. A sitter was not assigned to the patient.


I. Record review of Patient #1's Computed Tomography (CT) scan (a detailed x-ray of the patient's head), performed three times after the fall on 09/21/17 as ordered by the physician, indicated a bleed on the right side of his brain. The first CT scan was ordered after the fall at approximately 5:30 am. Two subsequent CT scans were ordered and performed at 12:39 pm, and 7:52 pm on 09/21/17 after the fall. Both scans indicated the same result of a bleed on the right side of the brain. A fourth CT of the head was performed on 09/22/17.


J. On 11/15/17 at 3:20 pm during interview, the Director of Quality (DoQ) and Director of Nursing (DoN) confirmed the photos were not dated, timed, or validated with a signature. DoQ was asked if she completed a root cause analysis. DoQ replied, "No. But we did investigate." DoQ was asked when she believed the photos were taken. DoQ stated, "We believed the photos were taken in the Emergency Department on the day of his [Patient #1's] arrival." DoQ was asked, "How do you know when the photos were taken?" DoQ stated, "We just assumed the injury was caused by a fall at home. We just don't know."


K. On 11/16/17 at 3 pm during phone interview, the sister and Power of Attorney of Patient #1 offered the following: "I came when [Patient #1] was admitted. I asked them to not leave him alone. I was afraid he would fall." She was asked if she had received a Death Certificate from the Office of the Medical Investigator. She stated, "Yes. And it said the fall contributed to his death. They called it blunt force trauma." The OMI (final) report was requested but was not available at the time of writing this report from the sister/ Power of Attorney and OMI.


L. Record review of the Discharge Summary indicated Patient #1 died shortly after vomiting fluid and aspirating on 09/22/17 while an inpatient in ICU. Nursing notes indicated Patient #1 received only CPR. He was not intubated and no note by a respiratory therapist was found.



Note: Physical symptoms of closed head injury with increase cranial pressure in adults includes nausea and vomiting. (Medical Physiology, Guyton and Hall, 2006)

Based on record review and interview, the hospital failed to perform a comprehensive investigation focusing on systems or other comprehensive method as part of their investigation into the cause of the fall and injury of Patient #1. By not fully investigating, the hospital could not determine when the fall took place or why Patient #1 fell. This failed practice of an incomplete investigation and review could contribute to injuries and harm for other patients. The findings are:


A. Record review of the Emergency Department (ED) Nurse Documentation dated 09/19/17 indicated "20:46 Screening: Abuse assessment: No assessment findings of abuse such as: unexplained injuries or bruising, suspicious burns, signs of withdrawal, depression, or fear of others. Assessment for neglect: No signs or indications of neglect noted, such as: exploitation, malnutrition, or poor hygiene. Fall Risk: 0-2 points- Low risk; fall risk bundle not initiated."


B. Record review of the electronic medical record on admission on 09/20/17 of Patient #1's fall risk assessment indicated he was calculated to have a risk score of 100 points. Any number greater than 45 was considered high risk for fall. Patient #1 was seen in the ED on 09/19/17 for nausea and assessment of chronic bowel problem. He was admitted to the medical/surgical unit early in the morning of 09/20/17. Nursing notes identified Patient #1 fell on the morning of 09/21/17 at approximately 5:30 am.


C. Record review of the hospital's undated fall protocol for Patient #1 indicated the hospital considered the use of a sitter (a staff member who stays with the patient in order to prevent falls), optional not mandatory. The protocol did not designate a risk number when the use of a sitter would be mandatory. A sitter was not assigned.

Review of Hospital Fall Record identified that patient #1 sustained an unobserved fall and was found on the floor in his room at 05:45 am on 21/2017. The fall resulted in a hematoma (a solid swelling of clotted blood within the tissues) to his head. Progress note dated 9/21./2017, reveals that pt #1 sustained a fall in the morning of 09/21/2017 resulting in blunt force trauma to the right front of the temple region of his head. The patient received a CT Scan at 5:54 am which revealed a subdural bleed (bleeding between the brain and its outermost covering) with a right to left midline shift (a shift of the brain past its center line.) Midline shift is often associated with high intracranial pressure (ICP), which can be deadly.) (Medical Physiology, Guyton & Hall , 2006.) Pt #1 was moved to the Intensive Care Unit (ICU). Pt #1 received two additional CT scans one at 12:39 pm and one at 07:00 am on 9/22/2017 both revealed that there was no longer a midline shift and no appreciable difference in the size of the bleed since the first scan.


D. Record Review of Patient #1's Computed Tomography (CT) scan (a detailed x-ray of the patient's head), performed twice on 09/21/17, indicated a bleed on the right side his brain.


E. Record review of Patient #1's medical record revealed pictures of injuries after a fall were not dated or timed or signed.


F. Record review of the Discharge Summary for Patient #1 indicated: Discharge diagnoses: ileus (no movement in bowel), subdural hematoma (a bleed in the brain), aspiration resulting in death, severe mental retardation, chronic obstructive pulmonary disease (degenerative lung disease).


G. On 11/15/17 at 3:20 pm during interview concerning the investigation performed, the Director of Quality confirmed the photos were not dated, timed, or validated with a signature. She was asked if she completed a root cause analysis. She replied, "No. But we did investigate." She was asked when she believed the photos were taken. She stated, "We believed the photos were taken in the Emergency Department on the day of his [Patient #1's] arrival." She was asked, how do you know when the photos were taken? She stated, "We just assumed the injury was caused by a fall at home." The Director of Quality made no mention of Patient #1 vomiting and aspiration just before his death in all the interviews with her. She was asked if a more thorough review such as a root cause analysis would have discovered the errors in charting, she replied, "Yes, it would. We will do one now."


H. On 11/16/17 at 3 pm during phone interview, the sister and Power of Attorney of Patient #1 offered the following: "I came when [Patient #1] was admitted. I asked them to not leave him alone. I was afraid he would fall." She was asked if she had received a Death Certificate from the Office of the Medical Investigator. She stated, "Yes. And it said the fall contributed to his death.They talked about blunt force trauma to his head." The OMI (final) report was requested but was not available at the time of writing this report.

Based on record review and interviews, the hospital failed to assign staff to stay with the patient full time to prevent the fall of Patient #1 after identifying Patient #1 as a high fall risk. The family requested on admission that someone be with the patient at all times. This failed practice lead to Patient #1 falling and injuring his head which likely contributed to his death. The findings are:


A. Record review of the Emergency Department (ED) Nurse Documentation dated 09/19/17 indicated "20:46 Screening: Abuse assessment: No assessment findings of abuse such as: unexplained injuries or bruising, suspicious burns, signs of withdrawal, depression, or fear of others. Assessment for neglect: No signs or indications of neglect noted, such as: exploitation, malnutrition, or poor hygiene. Fall Risk: 0-2 points- Low risk; fall risk bundle not initiated."


B. Record review of the electronic medical record of admission for Patient #1 on 09/20/17 indicated no physician order for a sitter for Patient #1 upon his admission. Patient #1 was seen in the ED on 09/19/17 for nausea and assessment of chronic bowel problem. He was admitted to the medical/surgical unit early in the morning of 09/20/17. Nursing notes identified Patient #1 fell on the morning of 09/21/17 at approximately 5:30 am.


C. Record review of the electronic medical record of Patient #1's fall risk assessment on 09/20/17 indicated his fall risk score at 100 points. Any number greater than greater than 45 was considered high risk.

The following is the Morse Fall Risk Assessment Tool used by the hospital to objectively measure Patient #1's potential risk of a fall. The protocol considers history of falls, secondary diagnoses such as pain, infection, etc., use of an ambulatory aid, intravenous access, gait, and mental status. Patient #1 was scored at 100 points out of a possible 140 points on the scale. Greater than 45 points is considered a "high risk" for falls.


D. Record review of the hospital's undated fall protocol indicated the hospital considered the use of a sitter (a staff member who stays with the patient in order to prevent falls), which is an optional fall risk prevention standard, and not mandatory at the high risk designation. A sitter was not assigned to Patient #1.


E. On 11/16/17 at 8:15 am during interview, the Director of Quality stated the following: "We did use sitters at one time but now we have only one part-time sitter. If we need to observe a patient we move the patient to the ICU [Intensive Care Unit] where we can watch them... the unit was full the day [09/20/17, [Patient #1] was admitted. He went to the Med/Surg [Medical Surgical Unit]. We did not assign a sitter."


F. On 11/15/17 at 8:00 am during interview, the Incident Management Bureau stated the family had requested Patient #1 not be left alone because of his many previous falls at home and other risk factors including his developmental delay, nausea, bowel problems, pain, etc.


G. on 11/16/17 at 3 pm during phone interview, the sister and Power of Attorney of Patient #1 offered the following: "I came when [Patient #1] was admitted. I asked them to not leave him alone. I was afraid he would fall." She was asked if she had received a Death Certificate from the Office of the Medical Investigator or OMI. She stated, "Yes. And it said the fall contributed to his death. They called it blunt force trauma." The OMI (final) report was requested but was not available at the time of writing this 2567.

Based on record review and interviews, the hospital staff failed to sign, date, and time photographs of injuries for Patient #1. This failed practice prevented the hospital from determining the date of injury for Patient #1. Incomplete medical records can potentially harm patients by limiting the completeness and accuracy of information providers use to manage care. The findings are:


A. Record review of the Emergency Department (ED) Nurse Documentation dated 09/19/17 indicated "20:46 Screening: Abuse assessment: No assessment findings of abuse such as: unexplained injuries or bruising, suspicious burns, signs of withdrawal, depression, or fear of others. Assessment for neglect: No signs or indications of neglect noted, such as: exploitation, malnutrition, or poor hygiene. Fall Risk: 0-2 points- Low risk; fall risk bundle not initiated."


B. Record review of the medical record for Patient #1 indicated he was seen in the ED on 09/19/17 for nausea and assessment of chronic bowel problem. He was admitted to the medical/surgical unit early in the morning of 09/20/17. Nursing notes identified Patient #1 fell on the morning of 09/21/17 at approximately 5:30 am.


C. Record review of the medical record for Patient #1 indicated photos of head injuries which were not labeled with the date or time, or a name of the person who took the photos. This made it impossible to verify whether the fall with injury occurred at home before the hospitalization or during a fall in the hospital. The photos were likely taken after Patient #1's fall in the hospital on 09/21/17 as confirmed by the admission Nursing assessment cited above. Patient #1 was admitted to the hospital on 09/20/17 and fell and hit his head on 09/21/17 at approximately 5:30 am.


D. Record review of Computed Tomography (CT) scans of Patient #1's head were performed at 5:55 am on 09/21/17 after the fall. The scan indicated a bleed in his head from his frontal area (the forehead), through the temporal area (on the side of the head), and to the parietal area (the rear of the head). Two subsequent CT scans were ordered and performed at 12:39 pm, and 7:52 pm on 09/21/17. The scans confirmed the bleed in the brain of Patient #1.


E. On 11/15/17 at 1:30 pm during interview, the Director of Quality confirmed the photo's of the injuries for Patient #1 were not dated or timed. She was asked if she had another way of confirming when the photos were taken. She stated, "We have erased the pictures from the camera [with the date]. We have looked for another confirmation of the dates of the photo but could not find one." The nurse who shot the photos was not available as she was no longer employed at the hospital.


F. Record review of the Discharge Summary for Patient #1 indicated:

1. Discharge diagnoses: ileus [no movement in bowel], subdural hematoma (a bleed in the brain), aspiration resulting in death, severe mental retardation, chronic obstructive pulmonary disease (degenerative lung disease).

2. Patient #1 died shortly after vomiting coffee grounds (blood) fluid and aspirating on 09/22/17. Clotted blood appears as coffee grounds in vomit.



G. On 11/16/17 at 3 pm during phone interview, the sister and Power of Attorney of Patient #1 offered the following: "I came when [Patient #1] was admitted. I asked them to not leave him alone. I was afraid he would fall." She was asked if she had received a Death Certificate from the Office of the Medical Investigator. She stated, "Yes. And it said the fall contributed to his death." The OMI (final) report was requested but was not available at the time of writing this 2567.