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Based on record review and interview, the facility failed to ensure the safety of 1 (#1) of 10 (#1 through #10) patients, evaluated in the Emergency Department (ED). The facility nursing staff failed to document the time, location, and circumstances related to pt #1 fall in the Fast Track ED of the facility. The facility nursing staff failed to document an initial assessment of pt #1 injuries. There were no vitals signs, neurological evaluation, or injury assessment documented prior to transferring pt #1 to a primary ED room for treatment.


Refer to A 0144

Based on record review and interview, the facility failed to ensure the safety of 1 (#1) of 10 (#1 through #10) patients evaluated in the Emergency Department (ED). The facility nursing staff, failed to document the time, location and circumstances of pt #1's fall in the Emergency Department Fast Track. This fall resulted in injuries. The facility Fast Track nursing staff failed to document an initial assessment of pt #1's injuries before he was transferred to the Emergency Department trauma area for evaluation. There were no vitals signs, neurological evaluation, or injury assessment documented prior to transferring pt #1 to a primary ED room for treatment.


This deficient practice had the likelihood to effect all patients of the facility.


Findings:

On 4/25/2019, in the conference room the Medical Record (MR) for patients (Pt) #1 through #10 were reviewed. Of the 10 patients, Pt #1 arrived at the ED on 3/24/2019 with a closed head injury following a witnessed fall at a long term care facility. Copies of Pt #1's MR from the long term care facility were identified in the hospitals MR and indicated Pt #1 suffered from dementia, muscle wasting with poor gait and balance. He also suffered from seizures, with a history of falls and an unspecified psychosis. Pt #1 was placed in a "Fast Track" bed of the ED, to the immediate right of the nurses station. The room had a door with a large window in the upper half of the frame.


After physician evaluation and ordered testing was completed, it was determined Pt #1 had suffered a fracture of his nasal bone, (broken nose). Pt #1 was stabilized by the ED physician, his nasal cavity was packed, bleeding was controlled and no other injuries were documented in the MR of Pt #1. The medical record indicated Pt #1 was stable for discharge. The Long Term Care facility was notified to come pick Pt #1 up from the ED and that he was stable to return to that facility.


After the Long Term Care facility had been notified of the pending discharge, Pt #1 crawled off the bed and immediately fell forward onto the floor re-injuring his fractured nose and adding additional fractures to his Zygomaticomaxillary area (cheek bone, orbital bones and floor of the maxillary area on his left side).

Review of Pt #1's MR found no time, place, or witness of pt #1's fall and subsequent injury. There were no neuro checks recorded, no vital signs were recorded, and no assessment of injury or initial emergency treatment was documented after the fall in the "Fast track" where Pt #1 was assigned. The MR indicated Pt #1 was moved from room #7 on the Fast track side to Room #13 on the ED side. No explanation was documented in the MR from the Fast Track nursing staff.

During interview with the Chief Nursing Officer on the morning of 4/25/2019, it was determined the Registered Nurse (RN), Staff #10, who documented the history of Pt #1's initial fall and subsequent fall, was the ED nurse who assumed care of Pt #1 after transferring from room #7 to room #13. Staff #10 was not the responding RN, who first found Pt #1 in the floor face down from a unwitnessed fall. No documentation was recorded from the Fast Track RN who was the first responder. No neuro assessment was identified in the Fast Track nursing assessment for the initial fall or the subsequent fall.

Vital signs were recorded on 3/24/2019 at the following Military times, after Pt #1 had fallen and the transfer to the trauma area of the ED had taken place. The sequence of the documentation was blood pressure, pulse, respiration, temperature and pulse oxygen saturation levels.

1538 156/99, 73, 18, 98.6 orally, 96% on room air
1723 155/107, 90,16, 98.6 Axillary, 96% on room air
1828 138/99, 80, 16, no temperature recorded, 94% on room air
2000 159/97, 90, 19, no temperature recorded, 88% on room air
2040 159/97, 90, 19, 98.6 orally, Pulse oxygen saturation recorded as 94% on 15% face mask


The ED RN documented a Glasgow comma score of 14 at 1536 and 15 at 1705 respectively and a trauma score of 12 at 1828. The trauma score indicated spontaneous eye response.


The full review of Pt #1 MR identified the nursing staff failed to document the time of the second fall, the location of the second fall while in the Fast Track area, or an initial assessment of Pt #1 injuries after the second fall. It was not clear in the documentation who was the first responder to Pt #1 after this fall or if an initial assessment occurred, and what the initial emergency treatment was for Pt #1.

Based on interview and record review, the facility's Emergency Department Registered Nursing (RN) staff failed to follow existing nursing policy for Fall Prevention and Safety Watch, which resulted in the fall with injury of 1 (#1) of 10 (#1 through #10) patients, who were evaluated and treated in the facility's ED from March 2019 through April 26, 2019.

Refer to A0395

Based on interview and record review, the facility's Emergency Department (ED) Registered Nursing (RN) staff failed to follow existing nursing policy for Fall Prevention and Safety Watch, which resulted in the fall with injury of 1 (#1) of 10 (#1 through #10) patients reviewed, who were evaluated and treated in the facility's ED.

This deficient practice had the likelihood to effect all patients of the facility's ED.


A review of pt #1's MR identified nothing documented regarding assessment of the lab abnormalities and co-morbidities that had the likelihood to effect Pt #1's mobility and potential for fall.

On 4/226/2019 in the morning, an interview with the Chief Nursing Officer (CNO) confirmed the Morse Fall scale was not what the facility's electronic program had built into it and therefore the nurses did not use the Morse Fall Scale but the program in use was similar.

It was also brought to the attention of the CNO, that the 30 minute safety rounding was not followed prior to or after Pt #1's fall. A review of the timeline found in Pt #1's MR identified a gap of greater than 1 hour (1 and 1.4 hours) between 1745 and 1900 where no documentation was identified. Again at 1910 -2017 greater than 1 hour (1 hour 7 minute) between documentation. The CNO confirmed the MR findings.

The documentation indicated that by 1910 Pt #1 had fallen twice with injury, once while in the ED. There was no documentation of implementation of the Facility's fall risk policy and no documentation of implementation the Safety Watch policy had been implemented.

An interview with the Quality Director confirmed the facility policies had not been followed and that the "Yellow" fall risk supplies ( yellow arm bands for pt's, cards to remind patient to "call don't fall", non skid socks and fall pads) were not available on the day Pt #1 fell and sustained greater injury than he had upon arrival to the ED.


On 4/26/2019 the facility's nursing policy for "Fall Prevention Policy, 9.6" last reviewed 2/2019 revealed the following purpose and policy actions to be taken by the nursing staff.

"Purpose: The Fall Prevention Policy purpose is to (1) establish a multi-disciplinary approach to fall prevention and implement fall preventions strategies to prevent falls and (2) through the use of of an evidenced based fall screening tool (Morse Fall Scale) and the implementation of prevention/protective fall interventions to prevent falls and falls with injury.

Policy: This fall prevention policy applies to all inpatient/limited outpatient care settings.

Definition: A. For the purpose of consistent interpretation, a fall is defined as:

Patient fall is a sudden, unintentional decent, with or without injury to the patient that results in the patient coming to ret on the floor.

2. Anticipated Physiological Falls: Factors associated with unknown fall risks as indicated on the Morse Fall Scale are predictive of a falls occurring: Loss of balance, impaired mobility, impaired gait, impaired cognitive/confusion, impaired vision. Falls that we anticipate will occur due to the patient's existing physiological status, history of falls, and decreased mobility upon assessment."


"Policy Safety Watch, 9.36", last reviewed 6/2017 revealed the following purpose and policy actions to be taken by the nursing staff.

"Purpose: To provide a framework to maintain safety for our patients at risk.

Policy: Through an evidence-based program and standardized algorithm, staff will identify patients at risk using an at-risk-for -harm scale, assess for root causes of the risk, and implement interventions to maintain safety.

Procedure: 1. Through the use of Patient History, Care Planning and Bedside Report, a need for assistance is identified. The patient will be rated by the following scale.

5 points: Self abusive or dangerous to self**
At risk of fall with injury

3 points: Unable to follow safe instructions

2 pints: Danger to others

1 point: wanders

If greater than 4 implement safety Watch algorithm

3. If total points greater than or equal to 4, assess for potential root cause and address causes as appropriate. Potential causes could be related to.

*Abnormal lab value

* review medication causes

*Assess vita signs, including pulse oxygen saturation and blood glucose

* Assess pain and discomfort

*Consider potential ETOH (alcohol) and drug withdrawal.

4. Determine interventions strategies for harm, such as

* Fall precautions

* Orientation strategies

* Provide diversion activities, provide glasses's or hearing aids, if needed

* Encourage family to stay

5. If interventions unsuccessful, escalate to Safety Watch protocol.

* Round on patient every 30 minutes

*Advance Rounding every 15 minutes if needed

* Advance to 1:1 nursing care when safety Watch every 15 minutes fails

* If possible and appropriate, cohort patients in semi private room with 2:1 nursing care.

7. Document all assessments and interventions in patient electronic record."



On 4/26/2019 a review of pt #1's MR indicated the following:

Pt #1 was presented to the ED on 3/24/2019 at 1531 (military time). Physician Assistant, Staff #8 saw Pt #1 upon arrival. At 1555, was screened by the medical provider. No medical history was identified. The physician ordered testing indicated an elevated blood sugar of 191 (normal is 70-110). Pt #1 was given 10 units of Lantus insulin. His magnesium was low at 1.5 (Normal 1.8-2.4), positive for Benzodiazipine, and elevated Tegretol level at 13.7 (normal range is 4.0-10.0).

A review of documentation submitted by the Long Term Care facility provided the ED physicians and nurses with the following diagnosis.

1. Dementia
2. Abnormal weight loss
3. Anxiety disorder
4. Unspecified convulsions
5. Unsteady on feet
6. Hypomagnesium
7. Difficulty walking
8. Repeated falls
9. Muscle weakness
10. Muscle wasting
11. Unspecified psychosis
12. Bipolar disorder
13. Primary osteoarthritis.

Medications identified on the Long Tern Care facility medication record which can contribute to poor judgment and falls were as follows:

1. Zyprexa-antipsychotic
2. Tegretol-anti-seizure
3. Gabapentin-neuropathy drug

Based on record review and interview, the facility failed to establish policy that addressed guidance of staff within the Emergency Department's (ED) to meet the safety needs of dementia patients, whose short term memory and inability to comprehend their own limitation contributed to their poor judgment resulting in injuries such as falls.

This deficient practice had the likelihood to affect all patients who present to the ED who were memory impaired.

Refer to A1104

Based on record review and interview, the facility failed to establish policy that addressed the need of staff within the Emergency Department's (ED) to meet the safety needs of dementia patients, whose short term memory and inability to comprehend their own limitation contributed to their poor judgment resulting in injuries such as falls. This failure affected all potential geriatric and/or dementia patient who sought treatment within the ED from Marched 2019 through April 26, 2019.

This deficient practice had the likelihood to effect all patients of the ED presenting with memory impairment.


Findings:

On 4/26/2019, a morning interview with the Quality Director and the Chief Nursing Officer (CNO) confirmed the existing policy did not offer guidance to staff when interacting with dementia patient or patients whose short term memory did not allow them the remember and safely follow instruction. They confirmed a patient with dementia would not likely think to, "Call for help", before attempting to leave the bed and thereby sustain a fall or other injury.

On 4/25/2019, during a tour of the ED and interview with the ED Nursing Director, Staff #7 confirmed she had met with her nursing staff during huddles but had no signature of staff in attendance, and no documentation of the topic that was presented in the huddles. Staff #7 confirmed she had begun training on the existing policy for which her staff had not previously followed, but again there were no signatures of staff who were in attendance.

During the interview, the CNO offered evidence of a policy review and changes that included structured intervention for the staff when interacting with dementia patients or patients with short term dementia.

Further the CNO confirmed the policy changes were to be brought before the Governing Body at their next meeting which was planned for later in the month. The policy also included a documentation log where every 10 minutes a dementia patient would be visually checked for safety and the documentation would be maintained on the log. The policy would also include change to bed type and height to reduce injury should a patient be able to climb out of bed between the 10 minute visual checks.

The CNO confirmed staff had not yet been trained as the policy had not yet been presented before the Governing Body and medical staff for approval.


On 4/26/2019, the facility's nursing policy for Fall Prevention Policy, 9.6 last reviewed by facility on 2/2019, was reviewed. The policy indicated the following purpose and policy actions to be taken by the nursing staff.


"Purpose: The Fall Prevention Policy purpose is to (1) establish a multi-disciplinary approach to fall prevention and implement fall preventions strategies to prevent falls and (2) through the use of of an evidenced based fall screening tool (Morse Fall Scale) and the implementation of prevention/protective fall interventions to prevent falls and falls with injury.

Policy: This fall prevention policy applies to all inpatient/limited outpatient care settings.

Definition: A. For the purpose of consistent interpretation, a fall is defined as:

Patient fall is a sudden, unintentional decent, with or without injury to the patient that results in the patient coming to ret on the floor.

2. Anticipated Physiological Falls: Factors associated with unknown fall risks as indicated on the Morse Fall Scale are predictive of a falls occurring: Loss of balance, impaired mobility, impaired gait, impaired cognitive/confusion, impaired vision. Falls that we anticipate will occur due to the patient's existing physiological status, history of falls, and decreased mobility upon assessment."


Policy Safety Watch, 9.36, last reviewed by facility on 6/2017 was reviewed. The policy indicated the following purpose and policy actions to be taken by the nursing staff.

"Purpose: To provide a framework to maintain safety for our patients at risk.

Policy: Through an evidence-based program and standardized algorithm, staff will identify patients at risk using an at-risk-for -harm scale, assess for root causes of the risk, and implement interventions to maintain safety.

Procedure: 1. Through the use of Patient History, Care Planning and Bedside Report, a need for assistance is identified. The patient will be rated by the following scale.

5 points: Self abusive or dangerous to self**
At risk of fall with injury

3 points: Unable to follow safe instructions

2 pints: Danger to others

1 point: wanders

If greater than 4 implement safety Watch algorithm

3. If total points greater than or equal to 4, assess for potential root cause and address causes as appropriate. Potential causes could be related to.

*Abnormal lab value

* review medication causes

*Assess vita signs, including pulse oxygen saturation and blood glucose

* Assess pain and discomfort

*Consider potential ETOH (alcohol) and drug withdrawal.

4. Determine interventions strategies for harm, such as

* Fall precautions

* Orientation strategies

* Provide diversion activities, provide glasses's or hearing aids, if needed

* Encourage family to stay

5. If interventions unsuccessful, escalate to Safety Watch protocol.

* Round on patient every 30 minutes

*Advance Rounding every 15 minutes if needed

* Advance to 1:1 nursing care when safety Watch every 15 minutes fails

* If possible and appropriate, cohort patients in semi private room with 2:1 nursing care.

6. Document all assessments and interventions in patient electronic record."