HospitalInspections.org

Based on interview, record review and policy review, it was determined the facility failed to ensure a registered nurse adequately supervised 1 (Patient #1) of 10 sampled patients, resulting in a fall with serious injury. Findings include:

Review of Patient #1's medical record, the patient of concern, revealed she was an 80-year-old female who was admitted to the hospital through the emergency department on 10/24/2021 with chief complaint of multiple falls at home and diagnosis of weakness, fall, and cerebrovascular accident (a loss of blood flow to part of the brain which damages brain tissue). According to Emergency Department (ED) physician note dated 10/24/2021 at 1439 Patient #1 required significant help walking to the bathroom, had dizziness and weakness and had experienced two falls at home before coming to the emergency room. Neurology consult dated 10/24/2021 at 1706 indicated Patient #1 had moderately severe disability - unable to walk without assistance and unable to attend to own bodily needs without assistance.

Review of Hester Davis Fall Risk Assessment for Patient #1 on 10/25/2021 at 1716 revealed a total score of 12.

Review of medication Administration Record for Patient #1 revealed Ativan 0.5mg administered intravenously (through catheter into vein) on 10/25/2021 at 1124.

Review of nursing note by radiology holding registered nurse (RN) (Staff O), on 10/25/21 at 1509 revealed Patient #1 arrived in IR (interventional radiology) holding from MRI (magnetic resonance imaging - medical imaging technique used to create detailed images of organs and vessels in the body) and needed to use the restroom, where she was taken by Staff O and Staff P (IR RN) using a walker. Once in the bathroom, Patient #1 was left in the bathroom and told to use the call light when she was done. One minute later a crashing sound was heard, Patient #1 was found on the ground on top of her walker. The note indicates that Patient #1 had a laceration above her right eye, a STAT (immediate) CT of the head was ordered, and Patient #1 was returned to her unit (5 West).

Review of CT of head for Patient #1 dated 10/25/2021 at 1359 revealed findings to include: intracranial hemorrhage frontal lobes, multiple acute facial fractures, nondisplaced right orbital floor fracture (bones around Right eye), right lamina papyracea medial blowout fracture containing orbital fat (bones around the right eye), minimally displaced comminuted right lateral orbital wall fracture (bones around the right eye), minimally displaced right zygomatic arch fracture (facial bone), subarachnoid hemorrhage (bleeding in the space surrounding the brain).

Review of Trauma consult dated 10/25/2021 at 1839 revealed Patient #1 had experienced a fall from the toilet while in the hospital. She had received Ativan for anxiety due to MRI and was unaccompanied to the bathroom. CT (Computer tomography - radiological exam which provides computerized cross-sectional images of the body) face showed acute right zygomatic arch and lateral maxillary wall fractures (right facial area), acute lateral inferior and medial right orbital wall fractures (around the eye), acute right nasal bone fractures, acute nondisplaced acute inferior medial left maxillary ridge wall fracture (facial left). CT of head revealed two small acute hyperdense subarachnoid hemorrhage (bleeding in the space that surrounds the brain). Patient also complained of right wrist pain. Patient #1 had Right peri-orbital erythema (swelling around right eye), nasal tenderness, bleeding from both nostrils, discharge from right eye, hemorrhage in right eye. had The note indicated Patient #1 had difficulty with lateral gaze, consultations were made for plastic surgery and ophthalmology.

Review of facility incident report for Patient #1 dated 10/25/2021 at 1325 indicated Patient #1 was ambulated to the bathroom using a gait belt and walker, and one assist. She was told to pull the red cord for assistance. A loud crash was heard. Patient #1 was found on the floor, snoring, laying on top of her walker, which had also crashed on the floor. Patient #1 had to be woken up, had a laceration above right eye, and did not recall the fall.

In an interview with the Director of Emergency Services (Staff F) and Manager of 5 West (Staff G) on 1/12/2022 at 1125, they stated when a patient is identified to be at risk for falls, a sign is placed on the patient's room indicated they are at risk for falls, a yellow wrist band is placed on the patient, they have bed and chair alarms in place and grippy socks on. This is all on the plan of care for the patient and will also be written on a "ticket to ride" which goes with the patient when they leave the unit with a patient transporter for any reason.

In an interview on 1/13/2022 at 1045, Staff O (IR RN) stated Patient #1 came to the holding area after having an MRI to wait for transport back to her room. She put her call light on and asked to use the bathroom. We checked her "ticket to ride" which stated she was up with one assist, was alert and oriented and seemed appropriate. Staff O said after Patient #1 was on the toilet they (himself and Staff P) left Patient #1 in the bathroom with the door closed. He stated a few seconds later they heard a loud crash, went to the bathroom and found Patient #1 on the ground. Staff O stated Patient #1 was bleeding from a laceration above her right eye. He stated the charge nurse was called, who came, ordered a CT of the head and took Patient #1 back to her unit. Staff O said he did not receive a report on Patient #1 and was not aware she had received Ativan. Staff O stated he wasn't sure if Patient #1 had a yellow fall risk bracelet on or not.

In an interview on 1/13/2022 at 1125, Staff P (IR RN) stated she took Patient #1 to the bathroom door on 10/25/2021, but at that point Staff O took over and got Patient #1 settled into the bathroom. Staff O did allow Patient #1 to stay in the bathroom alone and a few minutes later they both heard a loud noise. When they opened the bathroom door they found Patient #1 on the floor. Patient #1 had fallen forward from the toilet. Staff P stated Staff O reported to her that Patient #1 was groggy and snoring when he initially found her on the floor. Staff P said Patient #1 was wearing a yellow wrist band at the time she cared for her on 10/25/2021, and confirmed that she (Staff P) knew it meant a patient was at risk for falls.

In an interview on 1/13/2021 at 1050, Staff Q (Clinical Risk Manager) stated she was involved and reviewed the fall of Patient #1. She confirmed Patient #1 had been identified to be at risk for falls prior to her fall, was wearing a yellow wrist band, had been given Ativan (a sedating medication) and should not have been left alone in the bathroom. Staff Q stated all bills related to the fall of Patient #1 are being covered by the facility's insurance.

In an interview with Staff V, Nurse Educator, on 1/13/2022 at 1410, she stated all staff are educated at orientation on the falls policy.

Review of facility Policy Falls: Risk Assessment, Intervention, and Post-Fall Follow-up Inpatient dated 02/04/2020 revealed Based on the Fall Risk Assessment tool and clinical nurse judgement patients are identified as at risk for falls. Patients identified as "Moderate Risk" 11-14 using the Fall Risk Assessment tool are to have the following interventions: all low risk interventions plus: use gait belt with hands on during ambulation and transfers, remain with patient during toileting ...