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Based on record review and interview the facility failed to provide education to staff after staff failed to report an incidence of patient fall in the Emergency Room (ER) according to their policy/procedure dated March 2013.

Findings:

Review of self-report narrative revealed information there was complaint allegation that patient (#2) complained of headache that she believed resulted from a fall she sustained while she was a patient in the emergency room on 1/1/2015.
The patient was admitted in the Intensive Care Unit at an acute care facility on 1/2/2015 where CT scan revealed she had sustained a head injury. She was discharged from that facility on 1/4/2015.

Review of ER triage notes dated 1/1/2015 revealed Patient (# 2) was admitted to the ER at 4:34 pm with history of suicidal thoughts and history of attempting to grab a Police Officer's Gun.

On arrival to the ER the patient was in wrist restraints. She was diagnosed with emotional crisis. There was documentation the Mental Health Assessment Team evaluated the patient and transfer to a mental health facility was recommended.
Review of Nurses notes dated 1/1/2015 at 9:09 pm documented the patient was trying to run away from her room, was physically attacking staff and had to be placed in a secure holding room.

There was nurses notes dated 1/1/2015 at 9:12 pm that the patient "placed the mattress up against the window to obscure view and was calling racial slurs to the Security Officer at the door. At 9:25 pm the patient was screaming, yelling and banging the wall. She was medicated as ordered.

Review of Nurses' notes dated 1/2/2015 at 9:34 am revealed documentation that Patient (# 2) was awakened and taken by constable to the recipient hospital.

Review of the emergency room record revealed Patient (# 2) was in the care of emergency room staff for seventeen (17) hours prior to transfer. There was no documentation of the patient's condition at discharge from the emergency Room and no documentation that the patient fell during her stay in the ER.

Review of the facility's occurrence/incident report for January 1, 2015- February 11, 2015 revealed no report that Patient (# 2) fell while she was a patient in the ER.

Review of the facility's Event Report policy dated March 2013 documented the following information:

"It is the policy of the hospital to report an Event that impacts or has the potential to impact the safety of a patient, visitor or a facility providing patient care".

Review of the facility's action plan and in-service education revealed the plan did not include incident reporting protocol and training was documented for incident reporting.

During an interview on 2/11/2015 at 10: 30 am with the Chief Nursing Officer (CNO) she stated an intensive investigation was conducted. She stated staffs present in the ER were interviewed and all denied knowledge of the patient fall.

She stated review of the surveillance camera in the emergency room revealed the patient did fall backwards when staffs were trying to get the mattress from her. She stated Staff was disciplined. The CNO acknowledged that incident reporting was missed from the training.