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Based on policy and procedure reviews, medical record reviews and staff and physician interviews, hospital staff failed to maintain care in a safe setting by failing to prevent a fall in radiology for 1 of 1 radiology patients with an acute change in mental status who fell (Patient #7) and failing to prevent a cognitively impaired patient from unit elopement for 1 of 1 elopements (Patient #3).

The findings included:

1. Review of a policy titled "Fall Prevention Program", approved 09/12/2017, revealed "...The....Fall Prevention Program is intended to ....maintain a strategy....that focuses on the identification of patients with multiple risk factors for falls....minimization of environmental risks for falls ....A Falls Risk Protocol has been developed to guide nursing care of patients identified as high risk to fall in the hospital... ."

Review of the "Falls Prevention Protocol...", approved 09/11/2017, revealed "...RISK FACTORS: A. Intrinsic risk factors include advancing age, cognitive....D. Common causes of falls include: ...medication effects.... STAFF RESPONSIBILITIES: ....B. Staff Nurses: ... 3. Communicate fall rIsk.... C. When the patient leaves the department for tests of procedures....E. Ancillary Services.... 3. Be observant of patients with yellow armbands. ..."

Review of the "Hand Off Communication" policy, approved 04/04/2018, revealed "...Transferring to and from care and treatment areas C. In the event the patient is not accompanied by a RN (Registered Nurse) and transported by a Transporter only, a 'Ticket to Ride' is generated from the EMR for use when a patient leaves the inpatient unit and is transferred to or from a diagnostic area, such as radiology. A paper 'Ticket to Ride' contains essential clinical data regarding the patient's current condition.... This 'Ticket to Ride' accompanies the patient to and from the diagnostic testing process.... D. The electronic medical record may be accessed by all caregivers for necessary patient information. ..."

Medical Record review, on 09/03/2019, revealed a History and Physical, dated 03/11/2019 at 1221 and updated 03/19/2019 with no noted changes, which indicated Patient #7 was a 65-year old female with degenerative spondylolisthesis (displacement of a vertebra in the back) who was to be admitted for a "L4-5 decompression fusion (surgery designed to relieve pain and pressure on the spinal column)... ." Review of the Operative Note, dated 03/19/2019 at 1111, revealed back surgery, including a lumbar fusion was performed on that date.
On 03/21/2019 at 0406, Flowsheet review revealed a pain score of 6 and the Medication Administration Record (MAR) noted a Percocet (narcotic pain medication) tablet was given at 0408. Flowsheet documentation, at 0900, revealed a nursing assessment which noted Patient #7 to be alert and oriented x4 (times 4 - to person, place, time, and situation). At 0920 a notation was made that the pain score was 8 and the MAR revealed Patient #7 received Valium 5 mg orally and a Neurontin (Gabapentin) 300 mg capsule at 0921. On 03/21/2019, review revealed a Falls Risk Assessment was completed at 1500 with a score of 60 (high risk). Record review revealed a falls wrist band was on Patient #7 and a bed alarm was on. At 1500, a Nursing Flowsheet comment indicated Patient #7 was confused and could not work with PT (Physical Therapy) and that the attending physician was notified. On 03/21/2019 at 1609 Flowsheet review revealed a Neurological Assessment that stated "Disoriented to time; Disoriented to situation". At 1611, a RN Plan of Care review revealed "... Pt unable to follow certain commands. Dr. (Name) aware that pt is increasingly confused/drowsy. Gabapentin and morphine discontinued. Pt stable at this time. ..." Record review revealed at 1743 a Hospitalist Consult Note stated "...Acute encephalopathy - as per (family)...noticed patient started having some confusion yesterday afternoon. Can be medication related so I discontinued all sedating medications... Patient was noted to have 2 fever spikes on 2 different occasions. Will get.... chest x-ray...Manage tonight with PRN (as needed) Tylenol. ..." Review revealed the chest xray was performed at 1852. Review of a Head CT without contrast, at 2012, revealed the reason for the exam was "pt fell off radiology table r/o (rule out) injuries/ head trauma." Review of the result revealed "IMPRESSIONS 1. There is a large left parietal scalp hematoma with fluid level, likely due to active bleeding. . 2. No evidence of acute intracranial injury. No skull fracture. ..." Imaging review revealed a Lumbar Spine xray was also done on 03/22/2019 due to "Status Post Fall. Recent lumbar surgery. ..." Results revealed "...IMPRESSION: Stable appearance status post lower lumbar interbody fusion. No acute osseous abnormalities demonstrated radiographically. ..." Review of a Nursing Plan of Care note, on 03/22/2019 at 0830, revealed "Patient had a fall during a previous shift while in xray. Full assessment completed upon arrival back to unit. Patient was oriented only to self, poorly following commands.... RN accompanied patient to CT scan and xray of lumbar spine. On arrival back to unit, patient moved to room close to nurses station for patient's safety. Patient was drowsy and coughs with swallowing.... speech eval ordered, evening medications not given. Over the night, patient became more alert, following commands, and by 0600 she was oriented x4 and ambulating with assistance to the bathroom....VSS (vital signs stable). Will continue to monitor. ..." Record review revealed Patient #7 was discharged home 03/23/2019.

Review in the electronic medical record did not reveal a completed "Ticket to Ride" form from 03/21/2019. Review revealed a "Ticket to Ride" form could be pulled up, but the information on it was a generic form, not the specific form from 03/21/2019. Interview during record review revealed the "Ticket to Ride" forms were printed for transport witht the patient and were not a part of the permanent medical record.

Safety Event Report review, dated 03/21/2019 at 2034, revealed Patient #7 fell on 03/21/2019 at 1855. "...I was walking out of (x-ray room) to get an ED (Emergency Department) patient when I saw (Patient #7) laying on her back on the floor at the end and to the side of her stretcher. I immediately called.... and yelled out for other help....Dr. (name) and (name) came around the corner to access (sic) the patient....(Patient #7) was here for a cxr (chest x-ray) for AMS ( altered mental status) and was not verbal with information.... I asked her for her name and DOB (Date of birth) if she could stand and we only got mumbles back from her. After the xray she was placed in our holding area and was given a call bell in case she needed anything....When I found (Patient #7) both of the stretcher rails were up and the call bell was still in her bed....Prior to the fall, was the patient determined to be at risk for a fall? No....Was the patient oriented to person, place, and time prior to the fall? No....What risk factors did the patient have? Cognitive Impairment....Prior to the fall were there any fall precautions or fall prevention protocols in place? Unknown. ..."

Interview on 09/04/2019 at 1235, with Xray Technologist (Xray Tech) #1 revealed there were two Xray techs who did the chest xray on Patient #7. Interview revealed the patient was not alert and oriented or able to stand. Interview revealed when asked her name, Patient #7 did not answer, just moaned and groaned a little. Xray Tech #1 stated the chest xray was done on the stretcher, then Patient #7 was taken out of the xray room into a holding hallway area right outside of two adjoining xray rooms to wait for a transporter to take her back to her inpatient room. Interview revealed Xray Tech #1 went back into the main department (where computers were located) to document and Xray Tech #2 stayed in the xray room to clean the room. Once the exam was documented, Xray Tech #1 checked for the next xray, went to set up that room, and it was when she walked out that she noticed there was no patient on the stretcher, then noticed the patient was lying on the floor at the foot of the stretcher. Interview revealed Xray Tech #1 called for help and Xray Tech #2 and a supervisor came immediately. Interview revealed nurses did not give verbal reports when patients were coming to radiology, that the Ticket to Ride was on the chart. Interview revealed they (the Techs) "glance" at them as they move from one area to another. Interview revealed Xray Tech #1 did not think the patient would fall and did not think Patient #7 could sit up because they (the Techs) had to lift Patient #7 to put the board under her. Interview revealed a Radiologist came and assessed Patient #7 after the fall. Interview revealed the Radiologist tried to talk with the patient and asked her if she was hurt but Patient #7 did not answer, just moaned and groaned. Interview revealed after the Radiologist assessed her, Patient #7 was placed back on the stretcher and transported back to the nursing care unit. Interview revealed Patient #7 had a call bell, but Xray Tech #1 did not know if the patient was able to use it. Interview revealed the incident was discussed with the two involved Techs, but Xray Tech #1 was not aware of any department or hospital-wide changes.

Interview with Xray Tech #2, on 09/04/2019 at 1330, revealed Patient #7 came down for chest xrays and would not talk and would not stand. Interview revealed Patient #7 was left on the stretcher for the xray and afterwards was placed in the holding area. Interview revealed Patient #7 was given a call bell, but Xray Tech #2 did not recall if the patient was able to hold it. Xray Tech #2 stated she could not say if Patient #7 understood how to use the call bell. Interview revealed Xray Tech #2 went back to work and then heard Xray Tech #1 call for help. Interview revealed Patient #7 was on the floor in a puddle of urine. Xray Tech #2 stated "she must have climbed over the siderails". Interview revealed they called for help. Interview revealed they were able to sit the patient up with help, but that Patient #7 could not sit up and support her own weight. Interview revealed it was "pretty clear" the patient could not stand. Xray Tech #2 stated there were no specific guidelines about leaving patient's alone in radiology, but stated if patients were agitated or communicating they wanted to get up, she would stay with them. Interview revealed after the fall, "a lot of them" (Techs) were staying out more (with patients), but Xray Tech #2 was not aware of any documented department wide changes in processes/procedures.

Interview with RN #3, on 09/05/2019 at 0930, revealed RN #3 cared for Patient #7 on 09/21/2019. Interview revealed RN #3 was concerned because Patient #7 was a post op patient and was becoming more confused. Interview revealed RN #3 did not recall sending Patient #7 to Xray and did not recall the patient's confusion level when she went to radiology. Interview revealed she would have noted a big change in status. Interview revealed the Ticket to Ride printed out at the nurses station. Interview revealed it was an auto print- the nurse did not specifically document on the Ticket to Ride. Interview revealed that typically someone from radiology (or department the patient was going to) would call and ask if the patient was transporting with anything, such as oxygen or IVs and how they were coming, i.e. walk, wheelchair, stretcher. Interview revealed what was said depended on what was going on, that in this case she would have said they definitely needed a stretcher, that she was confused and "out of it right now". When asked if it was common for patients with that type of surgery to have confusion, RN #3 stated "not like that".

Telephone Interview with Radiologist #8, on 09/05/2019 at 1045, revealed he was the physician who examined Patient #7 after the fall. Interview revealed the patient was "awake, confused, not meaningfully responsive, but alert." Interview revealed the patient was moving all limbs, grabbing at the rails and trying to sit up.

Interview with Nurse Manager (NM) #7, the manager of Patient #7's inpatient unit, on 9/04/2019 at 1630 revealed the NM did not recall receiving anything specific from the Radiology manager or from the incident report related Patient #7's fall. Interview revealed if the fall had occurred on the inpatient unit, they would have done a review, but NM #7 was not involved of aware of one since the fall occurred in Radiology.

Interview with Radiology Manager #6, on 09/04/2019 at 1300, revealed the manager was not in the current role at the time of Patient #7's fall. Interview revealed Radiology Department leaders involved in the follow-up were not available for interview. The Radiology Manager stated she was not aware of any departmental wide changes that occurred after the incident. Follow-up interview on 09/05/2019 at 1030 revealed Radiology did not do department specific training on falls prevention, only the hospital wide training. Interview revealed Radiology Manager #6 identified this as an opportunity for the department.








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2. Review of a policy and procedure titled "Patient Elopement" effective 9/22/2017 revealed "PROCEDURE- The hospital makes every reasonable effort to determine the whereabouts of hospital inpatients..."

Review of the emergency department provider note dated 04/23/2019 at 1820 revealed an 81-year old female admitted to the hospital for "ataxia (impaired balance or coordination), TIA (transient ischemic attack-a brief stroke like attack that resolves within minutes to hours) and further care and evaluation." Review of the Nursing Note dated 07/03/2019 at 1503 revealed "This nurse rounded and visually checked on the patient around 1315. The patient was standing at the sink combing her hair. She was wearing her street clothes, which she frequently changes in and out of this entire admission. This nurse then went across the hall to room 3022 to complete patient care and dressing changes. At 1344 I heard the environmental services technician ask the nursing assistant in the hallway if 3016 was discharged. This nurse yelled back 'no' and quickly finished up patient care in 3022. This nurse did an inspection of the room and was then met in the hallway by the charge nurse. The charge nurse initiated the call to security and gave them the patients description. This nurse, the charge nurse, and security surveyed outside and around the hospital to find the patient. Per the volunteer at the patient tower entrance the patient stated that she was parked at the emergency room entrance and asked security to drive her around to the emergency room. Upon, returning to the floor the case manager stated she received a phone all [sic] from the patient's guardian. He said the patient was at her [sic] house and received a ride home from a random person from the hospital. (Named) Police was notified of the situation and will pick the patient up and return her to (Named Hospital). The provider was notified."

Interview on 09/04/2019 at 0930 with Registered Nurse (RN) #1 revealed she was Patient #3's primary nurse on 07/03/2019. Interview revealed Patient #3 "walked the unit" all the time during her admission but never attempted to elope. RN #1 stated Patient #3 was alert to self and place, "extremely forgetful", and easily redirectable. Interview revealed on 07/03/2019 RN #1 had checked on Patient #3 approximately 30 minutes prior to discovering Patient #3 had eloped from the unit. Interview revealed she did not receive re-education related to the incident and was unaware of any changes made to help ensure patients do not elope in the future.

Interview on 09/04/2019 at 0944 with Charge Nurse (CN) #1 revealed she was the charge nurse on 07/03/2019 when Patient #3 eloped from the unit. Interview revealed she notified protective services, house nursing supervisor, and started searching for Patient #3. Interview revealed she was unaware of any re-education related to the incident or of any changes made to help ensure patients do not elope in the future.

Interview on 09/04/2019 at 1235 with Nurse Manager (NM) #1 revealed she is the manager of the unit Patient #3 eloped from. Interview revealed Patient #3 had been admitted to the unit for approximately 6 weeks. Interview revealed Patient #3 frequently walked the halls of the unit and never posed an elopement risk. She stated "looking back" the fact that Patient #3 was allowed to wear street clothes may have contributed to her ability to elope. Interview revealed another contributing factor they identified was staff became "complacent" with Patient #3 because she had not given them any issues or reasons to be concerned for elopement. Interview revealed NM #1 held a debriefing with involved staff the day of the incident which covered rounding on Patient 3, events that lead up to the elopement such as the street clothes and complacency, discussion about watching for "triggers" that may cause a patient to elope and heighten their awareness in general.

NC00153482, NC00153051, NC00153262