HospitalInspections.org

Based on interview, and record review, the facility failed to ensure the patients' right to receive care in a safe setting was provided, for three of 30 sample patients (Patients 18, 20, and 21), when:

1. For Patients 18, and 21, who were a high fall risk, appropriate high fall risk interventions (steps taken to reduce the likelihood of falls by addressing various risk factors and implementing preventive measures) were not implemented according to facility policy;

This failure resulted in Patient 18 falling and had the potential to place 18 at risk for harm and injury. This failure also resulted in Patient 21 falling and sustaining severe injury requiring surgery. In addition, these failures may lead to other patients falling which may cause harm, injury, or death to the patients.

2. For Patient 20, who was a high fall risk, the facility did not notify the patient's family after a fall according to facility policy.

This failure had the potential to delay patient care and may lead to harm or injury.

Findings:

1a. On May 6, 2025, at 10:20 a.m., a review of Patient 18's medical record was conducted with Quality Coordinator (QC) 1. A facility document titled, "Trauma - History & Physical," was reviewed. The document indicated, "...[Name of Patient 18] presents as a trauma code s/p [status post] MVC [motor vehicle crash]...Due to [Patient 18's] altered mental status [change in consciousness that occurs when illnesses, disorders and injuries affect brain function] and likely unable to protect his airway so the decision was made to intubate [medical procedure where a flexible tube is inserted into the windpipe to maintain or establish an open airway] the patient ...assessment indicated multiple spinal fractures...acute subdural hemorrhage [a collection of blood between the inner layer of the skull and the surface of the brain] as well as few scattered SAH [Subarachnoid hemorrhage; medical emergency caused by bleeding into the space between the brain and the membranes surrounding it] overlying the L [left] parietal lobe [located near the back and top of the head]..."

An untitled facility document, dated March 24, 2025, at 10 a.m., was reviewed. The document indicated, "...Morse Fall Scale score, and risk level [a tool used to assess a patient's risk of falling. The total score can range from 0 to 125, with higher scores indicating a higher risk of falling]: 50 - High Risk...active fall prevention interventions: Bed/chair alarm...low bed...nonskid socks..."

An untitled facility document, dated March 24, 2025, at 8 p.m., was reviewed. The document indicated, "...Morse Fall Scale score, and risk level: 50 - High Risk...active fall prevention interventions: Bed/chair alarm...low bed...nonskid socks...Ambulation: Non ambulatory..."

An untitled facility document, dated March 25, 2025, at 12:40 a.m., was reviewed. The document indicated, "...Multidisciplinary Notes...Last rounded on patient at 0040 [12:20 a.m.] to provide care to other patient. At 0048 [12:48 a.m.] monitor tech [name of monitor tech 1] called upon entering the room noted patient was on the floor lying on his side. Noted the patient [Patient 18] was not breathing and did not have a pulse...patient was taken for stat CT [A CT (computed tomography) scan is an imaging test that helps healthcare providers detect diseases and injuries]. Upon return a full assessment was completed...no new injuries were present..."

A concurrent interview was conducted with QC1. QC1 stated it was documented on March 24, 2025, at 8 p.m. that a bed alarm was in use for Patient 18. QC1 further stated, there is no documentation that the alarm was going off prior to the fall.

On May 7, 2025, at 1:24 p.m., an interview was conducted with Monitor Tech 1. Monitor Tech 1 stated he had come back from assisting a patient to CT and when he saw Patient 18 wasn't showing on the monitor, Monitor Tech 1 went into the room and found Patient 18 on the ground face down. Monitor tech 1 stated he called for the nurse who was bathing a patient in a nearby room. Monitor Tech 1 stated Patient 18 had has previous moments of anxiety and restlessness and was altered due to a brain injury. Monitor Tech 1 further stated there was no bed alarm going off when he entered Patient 18's room. Monitor Tech 1 stated there was no bed alarm going off at the nurse's station prior to entering Patient 18's room.

On May 7, 2025, at 1:28 p.m., an interview was conducted with Unit Manager 1. Unit Manager 1 stated he was not on call at the time of the incident, but he is aware of what was discussed during the post fall debriefing. Unit Manager 1 stated it was determined that the bed alarm was not on at the time of the fall. Unit Manager 1 stated staff never heard a bed alarm going off, but he is unable to answer why the alarm was not on. Unit Manager 1 further stated, the policy for high fall risk patients like Patient 18, would be to have the bed alarm on. Unit Manager 1 stated Patient 18's bed alarm should have been on to help prevent falls.

1b. On May 7, 2025, at 9:36 a.m., a review of Patient 21's medical record was conducted with Patient Safety Coordinator (PSC) 1. A facility document titled, "Trauma - History & Physical," dated April 30, 2025, at 5:26 p.m., was reviewed. The document indicated, "...[Name of Patient 21]...activated as a trauma tier 1 [refers to the highest level of trauma care, typically for patients with the most severe and life-threatening injuries] after a fall in the ED [Emergency Department]. Patient was seen again for recurrent opioid overdose and was given Narcan [a medication that can reverse an opioid overdose] again...[Patient 21] fell backward striking his head to the floor...immediately placed in the trauma bay, was given 4mg [unit of measurement] of Narcan and was intubated for airway protection...attestations: Patient initially seen in the ED for opioid overdose...eloped from the ED and per reports, had an unwitnessed fall in a church...reported to have a witnessed fall with head strike in the ED...CT immediately obtained and showed a moderate size subdural hemorrhage and midline shift...planning to emergently take patient [21] to the operating room for decompressive craniectomy [a surgical procedure where a large portion of the skull is removed to relieve pressure within the skull, particularly in cases of severe swelling or bleeding in the brain]..."

An untitled facility document, dated April 30, 2025, at 3:16 p.m., was reviewed. The document indicated, "...Fall Risk Assessment ...history of falling: yes...Morse Fall Scale score and risk level: 70- High Risk...Active fall prevention interventions: low bed...supervised/assisted amb [ambulation; walking]..."

A facility document titled, "Patient Notes," was reviewed. The document indicated, "...4/30/25 1530 [March 30, 2025, at 3:30 p.m.] PT [Patient 21] combative with staff, refusing treatment, placed in line of sight of staff..."

A facility document titled, "Patient Notes," was reviewed. The document indicated, "...4/30/25 1645 [March 30, 2025, at 4:45 p.m.]... fall unwitnessed by this RN...multiple staff reported pt stood up at foot of gurney and saw pt fall back immediately...RN/MD at pt side immediately. This RN arrived at pt bedside, trauma code called immediately...see Trauma flowsheet for workup..."

An untitled facility document, dated April 30, 2025, at 3:46 p.m., was reviewed. The document indicated, "...Post Fall Assessment ...type of fall: witnessed...level of injury: Major...Deteriorating condition requiring transfer to higher level of care: yes..."

On May 7, 2025, at 11:15 a.m., an interview was conducted with the Director of the Emergency Department (DED). The DED stated Patient 21 came in by ambulance after he was found on the grass at the church. The DED stated the patient was given Narcan and woke up more stable and then went to sleep and was resting on a gurney in the hallway near a tech and across from the nurse's station. The DED stated the patient was sleeping in one moment, then woke up, stood up quickly and went down before anyone could reach him. The DED stated the patient was sent to trauma immediately and then had to be sent to surgery and the ICU [intensive care unit]. The DED further stated if a patient is identified as a high fall risk, they should be placed on all the interventions according to policy. The DED stated Patient 21 was refusing treatment at the time of the fall assessment and staff were not able to implement all interventions.

On May 7, 2025, at 1 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated Patient 21 came in by ambulance for an overdose. RN 1 stated the patient was given Narcan and placed in a bed next to the nurse's station to keep eyes on him. RN 1 stated when he came into the ED, he told us to leave him alone and did not want us near him. RN 1 stated the patient would have been a moderate to high fall risk but remembers patient refusing fall interventions. RN 1 stated the patient should have had intervention in place including yellow gown and socks, fall risk bracelet, and the bed alarm for gurneys, but they were not in place because the patient refused.

A review of the facility policy and procedure (P&P) titled, "Fall Prevention Plan," dated April 2022, was conducted. The P&P indicated, "...All patients will be evaluated for fall potential through completion of the appropriate falls risk assessment. This will occur during the initial admission assessment process and daily nursing assessment; at minimum once per shift...based on the level of fall risk, nursing interventions will be initiated and captured on the patient's plan of care...Adult fall prevention interventions to be implemented...Moderate/high fall risk (Morse score 25-69)...bed/chair alarm activated...Very high fall risk (Morse score 70+) ...Moderate/high risk precautions...yellow gown...following to be considered...sitter at bedside...following the calculation of a fall sore and risk level, the nurse will document all active, applicable interventions..."

2. On May 6, 2025, at 10:20 a.m., a review of Patient 20's medical record was conducted with Quality Coordinator (QC) 1. An untitled facility document, dated February 6, 2025, at 9:30 a.m., was reviewed. The document indicated, "...Fall risk...Morse fall scale score and risk level: 75- High Risk...active fall prevention interventions...bed/chair alarm...low bed...nonskid socks..."

An untitled facility document, dated February 6, 2025, at 9:39 a.m., was reviewed. The document indicated, "...was notified by nurse colleague that the patient [Patient 20] has fallen on the floor while he was attempting to get up out of the chair. Patient was assisted back to bed...full assessment completed. Patient states no pain or headache at this time...no deficit was found...doctors were notified..."

A concurrent interview was conducted with QC 1 during the record review. The QC 1 stated there is no documentation that Patient 20's family was notified of the patient's fall according to policy.

A review of the facility policy and procedure (P&P) titled, "Fall Prevention Plan," dated April 2022, was conducted. The P&P indicated, "...Post Fall Process...Notifications of the fall...at a minimum, the attending physician, nursing leader, and patient's legal representative will be notified as soon as possible...all notifications with date and time of fall will be documented in the HER [electronic health record]..."

Based on interview, and record review, the facility failed to implement their policy and procedures for three of 30 sample patients (Patients 18, 20, and 21), when:

1. For Patients 18, and 21, who were a high fall risk, appropriate high fall risk interventions (steps taken to reduce the likelihood of falls by addressing various risk factors and implementing preventive measures) were not implemented according to facility policy;

This failure resulted in Patient 18 falling and had the potential to place 18 at risk for harm and injury. This failure also resulted in Patient 21 falling and sustaining severe injury requiring surgery. In addition, these failures may lead to other patients falling which may cause harm, injury, or death to the patients.

2. For Patient 20, who was a high fall risk, the facility did not notify the patient's family after a fall according to facility policy.

This failure had the potential to delay patient care and may lead to harm or injury.

Findings:

1a. On May 6, 2025, at 10:20 a.m., a review of Patient 18's medical record was conducted with Quality Coordinator (QC) 1. A facility document titled, "Trauma - History & Physical," was reviewed. The document indicated, "...[Name of Patient 18] presents as a trauma code s/p [status post] MVC [motor vehicle crash]...Due to [Patient 18's] altered mental status [change in consciousness that occurs when illnesses, disorders and injuries affect brain function] and likely unable to protect his airway so the decision was made to intubate [medical procedure where a flexible tube is inserted into the windpipe to maintain or establish an open airway] the patient ...assessment indicated multiple spinal fractures...acute subdural hemorrhage [a collection of blood between the inner layer of the skull and the surface of the brain] as well as few scattered SAH [Subarachnoid hemorrhage; medical emergency caused by bleeding into the space between the brain and the membranes surrounding it] overlying the L [left] parietal lobe [located near the back and top of the head]..."

An untitled facility document, dated March 24, 2025, at 10 a.m., was reviewed. The document indicated, "...Morse Fall Scale score, and risk level [a tool used to assess a patient's risk of falling. The total score can range from 0 to 125, with higher scores indicating a higher risk of falling]: 50 - High Risk...active fall prevention interventions: Bed/chair alarm...low bed...nonskid socks..."

An untitled facility document, dated March 24, 2025, at 8 p.m., was reviewed. The document indicated, "...Morse Fall Scale score, and risk level: 50 - High Risk...active fall prevention interventions: Bed/chair alarm...low bed...nonskid socks...Ambulation: Non ambulatory..."

An untitled facility document, dated March 25, 2025, at 12:40 a.m., was reviewed. The document indicated, "...Multidisciplinary Notes...Last rounded on patient at 0040 [12:20 a.m.] to provide care to other patient. At 0048 [12:48 a.m.] monitor tech [name of monitor tech 1] called upon entering the room noted patient was on the floor lying on his side. Noted the patient [Patient 18] was not breathing and did not have a pulse...patient was taken for stat CT [A CT (computed tomography) scan is an imaging test that helps healthcare providers detect diseases and injuries]. Upon return a full assessment was completed...no new injuries were present..."

A concurrent interview was conducted with QC1. QC1 stated it was documented on March 24, 2025, at 8 p.m. that a bed alarm was in use for Patient 18. QC1 further stated, there is no documentation that the alarm was going off prior to the fall.

On May 7, 2025, at 1:24 p.m., an interview was conducted with Monitor Tech 1. Monitor Tech 1 stated he had come back from assisting a patient to CT and when he saw Patient 18 wasn't showing on the monitor, Monitor Tech 1 went into the room and found Patient 18 on the ground face down. Monitor tech 1 stated he called for the nurse who was bathing a patient in a nearby room. Monitor Tech 1 stated Patient 18 had has previous moments of anxiety and restlessness and was altered due to a brain injury. Monitor Tech 1 further stated there was no bed alarm going off when he entered Patient 18's room. Monitor Tech 1 stated there was no bed alarm going off at the nurse's station prior to entering Patient 18's room.

On May 7, 2025, at 1:28 p.m., an interview was conducted with Unit Manager 1. Unit Manager 1 stated he was not on call at the time of the incident, but he is aware of what was discussed during the post fall debriefing. Unit Manager 1 stated it was determined that the bed alarm was not on at the time of the fall. Unit Manager 1 stated staff never heard a bed alarm going off, but he is unable to answer why the alarm was not on. Unit Manager 1 further stated, the policy for high fall risk patients like Patient 18, would be to have the bed alarm on. Unit Manager 1 stated Patient 18's bed alarm should have been on to help prevent falls.

1b. On May 7, 2025, at 9:36 a.m., a review of Patient 21's medical record was conducted with Patient Safety Coordinator (PSC) 1. A facility document titled, "Trauma - History & Physical," dated April 30, 2025, at 5:26 p.m., was reviewed. The document indicated, "...[Name of Patient 21]...activated as a trauma tier 1 [refers to the highest level of trauma care, typically for patients with the most severe and life-threatening injuries] after a fall in the ED [Emergency Department]. Patient was seen again for recurrent opioid overdose and was given Narcan [a medication that can reverse an opioid overdose] again...[Patient 21] fell backward striking his head to the floor...immediately placed in the trauma bay, was given 4mg [unit of measurement] of Narcan and was intubated for airway protection...attestations: Patient initially seen in the ED for opioid overdose...eloped from the ED and per reports, had an unwitnessed fall in a church...reported to have a witnessed fall with head strike in the ED...CT immediately obtained and showed a moderate size subdural hemorrhage and midline shift...planning to emergently take patient [21] to the operating room for decompressive craniectomy [a surgical procedure where a large portion of the skull is removed to relieve pressure within the skull, particularly in cases of severe swelling or bleeding in the brain]..."

An untitled facility document, dated April 30, 2025, at 3:16 p.m., was reviewed. The document indicated, "...Fall Risk Assessment ...history of falling: yes...Morse Fall Scale score and risk level: 70- High Risk...Active fall prevention interventions: low bed...supervised/assisted amb [ambulation; walking]..."

A facility document titled, "Patient Notes," was reviewed. The document indicated, "...4/30/25 1530 [March 30, 2025, at 3:30 p.m.] PT [Patient 21] combative with staff, refusing treatment, placed in line of sight of staff..."

A facility document titled, "Patient Notes," was reviewed. The document indicated, "...4/30/25 1645 [March 30, 2025, at 4:45 p.m.]... fall unwitnessed by this RN...multiple staff reported pt stood up at foot of gurney and saw pt fall back immediately...RN/MD at pt side immediately. This RN arrived at pt bedside, trauma code called immediately...see Trauma flowsheet for workup..."

An untitled facility document, dated April 30, 2025, at 3:46 p.m., was reviewed. The document indicated, "...Post Fall Assessment ...type of fall: witnessed...level of injury: Major...Deteriorating condition requiring transfer to higher level of care: yes..."

On May 7, 2025, at 11:15 a.m., an interview was conducted with the Director of the Emergency Department (DED). The DED stated Patient 21 came in by ambulance after he was found on the grass at the church. The DED stated the patient was given Narcan and woke up more stable and then went to sleep and was resting on a gurney in the hallway near a tech and across from the nurse's station. The DED stated the patient was sleeping in one moment, then woke up, stood up quickly and went down before anyone could reach him. The DED stated the patient was sent to trauma immediately and then had to be sent to surgery and the ICU [intensive care unit]. The DED further stated if a patient is identified as a high fall risk, they should be placed on all the interventions according to policy. The DED stated Patient 21 was refusing treatment at the time of the fall assessment and staff were not able to implement all interventions.

On May 7, 2025, at 1 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated Patient 21 came in by ambulance for an overdose. RN 1 stated the patient was given Narcan and placed in a bed next to the nurse's station to keep eyes on him. RN 1 stated when he came into the ED, he told us to leave him alone and did not want us near him. RN 1 stated the patient would have been a moderate to high fall risk but remembers patient refusing fall interventions. RN 1 stated the patient should have had intervention in place including yellow gown and socks, fall risk bracelet, and the bed alarm for gurneys, but they were not in place because the patient refused.

A review of the facility policy and procedure (P&P) titled, "Fall Prevention Plan," dated April 2022, was conducted. The P&P indicated, "...All patients will be evaluated for fall potential through completion of the appropriate falls risk assessment. This will occur during the initial admission assessment process and daily nursing assessment; at minimum once per shift...based on the level of fall risk, nursing interventions will be initiated and captured on the patient's plan of care...Adult fall prevention interventions to be implemented...Moderate/high fall risk (Morse score 25-69)...bed/chair alarm activated...Very high fall risk (Morse score 70+) ...Moderate/high risk precautions...yellow gown...following to be considered...sitter at bedside...following the calculation of a fall sore and risk level, the nurse will document all active, applicable interventions..."

2. On May 6, 2025, at 10:20 a.m., a review of Patient 20's medical record was conducted with Quality Coordinator (QC) 1. An untitled facility document, dated February 6, 2025, at 9:30 a.m., was reviewed. The document indicated, "...Fall risk...Morse fall scale score and risk level: 75- High Risk...active fall prevention interventions...bed/chair alarm...low bed...nonskid socks..."

An untitled facility document, dated February 6, 2025, at 9:39 a.m., was reviewed. The document indicated, "...was notified by nurse colleague that the patient [Patient 20] has fallen on the floor while he was attempting to get up out of the chair. Patient was assisted back to bed...full assessment completed. Patient states no pain or headache at this time...no deficit was found...doctors were notified..."

A concurrent interview was conducted with QC 1 during the record review. The QC 1 stated there is no documentation that Patient 20's family was notified of the patient's fall according to policy.

A review of the facility policy and procedure (P&P) titled, "Fall Prevention Plan," dated April 2022, was conducted. The P&P indicated, "...Post Fall Process...Notifications of the fall...at a minimum, the attending physician, nursing leader, and patient's legal representative will be notified as soon as possible...all notifications with date and time of fall will be documented in the HER [electronic health record]..."