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Based on record review and interview, the facility failed to fully analyze an adverse patient event & implement preventative actions following a patient fall that resulted in significant injury ( Patient # 6).

Findings include:

TX 00258990

Record review of complaint intake # TX 00258990 read: "...90 year old female Patient # 6 was transported to ( facility ) ER because she was hypoglycemic ( low blood sugar). While in the emergency department (ED) Patient # 6 fell out of bed onto her face... she sustained a C-6 (spinal vertebra) fracture ..."

Patient # 6:

Record review of the ED record of Patient # 6 revealed she was 90 years old and arrived by ambulance on 11-17-16 at 7:28 p.m. She was Triaged at 7:42 p.m. Review of the triage assessment failed to reveal "Risk For Falls" was selected.

Further review of Patient # 6's record failed to reveal a fall risk assessment was documented. It was documented: "bed low position, side rails up, fall precautions."

Record review of nurse's notes dated 11-17-16 ( 9:09 p.m.) read: "stepped out of room to draw medications to be administered to other pts. While walking to room 5 across from patient's room, pt was observed climbing out of bed and was unable to catch the pt in time before falling...pt landed on her left side and hit her face causing a laceration to the forehead with bruising on her left upper extremity. Bleeding has been stabilized, c-collar applied before transferring pt back to the bed. Pt to be taken to CT immediately..." Review of CT scan report showed C-6 fracture. Patient # 6 was transferred to medical center for higher level of care.

Interview on 05-18-17 at 1:45 p.m. with Quality Manager # 3 she stated when incidents like this happen she forwarded them for investigation to the department manager. She was unsure of the Improvement actions taken following the fall of Patient # 6.

Interview on 05-18-17 at 2:15 p.m. ED Manager # 7 she stated "it was determined there was a history of falls that wasn't reported until after the fall. This was something that was missed. It was unclear if the C-6 fracture happened before or after the fall. If we had known of the history of falls, perhaps we'd have considered restraints; full history would have helped."

When asked what actions had been implemented to prevent future occurrences, ED Manager said "we already place elderly with altered mental status close to nurse's station and monitor them frequently. We identified the need to have better communication with EMS to identify patients at high risk for falls."

Review of the facility investigation of the fall of Patient # 6, dated 12-06-16, revealed the only contributory factor listed was: "RN did not get a full history from EMS about her history of falls and dementia until after the fall..."

[* it was documented upon Patient # 6 arrival at 1928: "pt is A & O x 1...had been diagnosed with advanced Alzheimer's per EMS..."]

The facility failed to analyze the overall process for determination of fall risk of ED patients. The facility failed to identify that a fall risk assessment was not included in the ED patient "Daily Focus Assessment" area in the EMR (electronic medical record). This was discovered during the present investigation ( Refer to A-0395).

In addition, the facility failed to identify the existing drop down screen at Triage that indicated: "Risk for Falls" was not being utilized by Triage nurse for patients who were clearly high risk for falls. This was discovered during the present investigation ( Refer to A-0395).

Interviews on 05-18-17 between 10 a.m. and 11 a.m with three(3) ED Registered Nurses (RN) [ RN # 4, #5, #6] failed to reveal a consistent understanding of facility requirements for assessing and documenting fall risk for patients in the ED.

Record review of facility policy titled" Risk Management: Unusual Occurrence Reporting General Guidelines" revised date 03/17, read: "Policy...D. Data collected through Unusual Occurrence Reporting System will be utilized as a means of identifying ..opportunities for improvement and/or on-going education. Appropriate interventions will be initiated to address the problems and prevent reoccurrence...Procedure...B. Follow-Up Actions...8. Trends and serious individual occurrences will be reported to the appropriate Executives...for follow-up and recommendations".

Based on observation, interview, and record review, the facility failed to ensure that a registered nurse supervised the care of 7 of 10 sampled Emergency Department (ED) patients ( Patients# 1, 2, 3, 5, 6,7,8).

Nursing failed to perform a fall risk assessment on all 7 patients [ three (3) sustained actual falls in the ER; three(3) were admitted to ER due to a fall.]

Findings include:

TX 00258990

Record review of complaint intake # TX 00258990 read: "...90 year old female Patient # 6 was transported to ( facility ) ER because she was hypoglycemic ( low blood sugar). While in the emergency department (ED) Patient # 6 fell out of bed onto her face... she sustained a C-6 (spinal vertebra) fracture ..."

Patient # 6:

Record review of the ED record of Patient # 6 revealed she was 90 years old and arrived by ambulance on 11-17-16 at 7:28 p.m. She was Triaged at 7:42 p.m. Review of the triage assessment failed to reveal "Risk For Falls" was selected.

Further review of Patient # 6's record failed to reveal a fall risk assessment was documented. It was documented: "bed low position, side rails up, fall precautions".

Record review of nurse's notes dated 11-17-16 ( 9:09 p.m.) read: "stepped out of room to draw medications to be administered to other pts. While walking to room 5 across from patient's room, pt was observed climbing out of bed and was unable to catch the pt in time before falling...pt landed on her left side and hit her face causing a laceration to the forehead with bruising on her left upper extremity. Bleeding has been stabilized, c-collar applied before transferring pt back to the bed. Pt to be taken to CT immediately..." Review of CT scan report showed C-6 fracture. Patient # 6 was transferred to medical center for higher level of care.

Interview on 05-18-17 at 11:50 a.m. with ER Manager # 7 she was unable to locate an area in the electronic ED record assessment area that addressed a fall risk assessment. Both she and the Quality Manager # 3 said at this time they thought it was there: "the same as the inpatient 'Morse fall risk assessment' ". Neither could locate this fall risk assessment on the ED record.

Patients # 1,2, 3, 5:

Record review of patient census and ED records on 05-18-17 revealed three (3) current ED patients had been admitted following a fall (Patients # 1, # 2 # 3 ) One (1) Patient # 5 was 95 yrs. old) admitted for dizziness & weakness]. None of these four (4) current patients had "Risk for Fall" screening indicator selected at Triage or a documented Morse fall risk assessment with fall prevention interventions selected. Interview with ED Manager # 7 on 05-18-17 at 12 p.m., she stated the fall risk assessments should be in the record.

Patients # 7, # 8 :

Record review of the ER fall data and fall investigations for 2016 & 2017 revealed:

Patient # 7 :

73 year old male admitted from nursing home, fell in ED on 4-8-17. He did not have "Risk for Fall" screening indicator selected at Triage or a documented Morse fall risk assessment with fall prevention interventions selected. Patient # 7 had documented cognitive impaired prior to fall.

Patient # 8:

24 year old behavioral health patient fell from bed in ED on 09-19-16. Patient # 7 had a sitter who stated "I did not see her fall." Patient # 8 did not have "Risk for Fall" screening indicator selected at Triage or a documented Morse fall risk assessment with fall prevention interventions selected.

Record review of facility policy titled " Falls-Fall Prevention," revised date 2/17, read: " All patients will be assessed for fall risk indicators and documented in the electronic medical record, The purpose of the falls prevention and fall management program is to promote patient safety by: A. identifying all patients for possible risks for falls through the use of the Morse Fall Risk Scale (MFS)...Prevention: yellow arm band, yellow non-skid socks and a falling star outside the door. Additionally, patients identified as high risk ...will wear a yellow gown....B, Assessment/ Reassessment: A MFS will be conducted upon admission and reviewed and updated per shift: a) upon admission b) per shift and c) when there are physical or psychological changes..."

Interview on 05-18-17 at 1:45 p.m. with Quality Manager # 3 she stated the facility "Falls-Fall Prevention" policy applied to ER patients and not just inpatients.

Interview on 05-18-17 at 3:15 p.m. with Associate Vice President/ Assistant Administrator # 2 she stated the "ER fall risk assessment piece was not included when the EMR was redesigned. The prior ER Director had this responsibility and it fell through the cracks".