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Based on observation, policy review, and interview, the clinic failed to ensure each patient was informed of their Patient Rights prior to providing care, potentially affecting all patients that receive care at the ambulatory outpatient clinic. This deficient practice has the potential to prevent patients from knowing each of their rights which may lead to harm and other adverse outcomes.

Findings Include:

Review of the Hospital's policy titled, "Patient Rights and Responsibilities," approved 04/2019, showed that "It is the responsibility of all staff to ensure that these rights are preserved for each patient . . . Ambulatory Clinic Patients: as part of the initial registration process, each patient or representative will receive a clinic brochure, which includes Patients' Rights and Responsibilities. If the patient lacks decisional capacity, the information will be given to family/patient representative on his/her behalf." Further review showed that the policy referred to "Patient Rights Document (Adult)."

Review of the Hospital's document titled, "Patients' Rights Document (Adult)," showed, "[The Hospital] is committed to respect and protect (sic) the rights of its patients. Honoring these rights is an important part of respecting and caring for you as a whole person. We are committed to relating to you in a way that respects your role in making decisions about your care . . . we need you to participate in decisions about your health care. By talking with your caregivers and actively participating in planning your care, you will help to ensure that the care you receive will respect your dignity and be in keeping with your desires and values."

Further review showed that the patient rights referred to in the Hospital's policy failed to include the contact information for patients to submit a complaint or grievance and failed to include the hotline telephone number to the State Agency; failed to include the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission; the right to care in a safe setting; and the right to be free from all forms of abuse or harassment.


During an observation on 08/11/22 at 8:35 AM showed a sign titled "Your Patient Rights and Responsibilities," posted in the waiting room, just left to the registration desks.

The sign showed that the posted rights failed to include the right to file a grievance and how to submit a grievance, who to contact regarding a grievance, and did not include the hotline telephone number to the state agency; the right to be free from all forms of abuse or harassment; and the right to access their medical records.

During an interview at the time of the observation, the surveyor asked Staff R, Registrar, for a copy of Patient Rights as they'd be given to patients. Staff R got a binder and brought it back to her desk. She flipped through a few pages and then went to the cabinet behind the registration desks and opened one. An unidentified staff next to her asked her what she was looking for. Staff R informed the unidentified staff that there weren't any copies of Patient Rights to provide to patients. Staff R came back to the surveyor and informed the surveyor that they only have what is posted on the walls.

During an interview on 08/10/22 at 12:50 PM, Staff C, Accreditation and Regulatory Compliance (ARC) presented a two-page document titled, "Before and After Your Visit," as the brochure the clinic provides patients. Staff C stated that the patients get this when they are a new patient and explained that the links on the document will direct patients to their Patient's Rights.

During an interview on 08/11/22 at 8:44 AM, Staff C, ARC, stated that the clinic does not have a brochure and that they do not document that patients have received patient rights in ambulatory outpatient clinics.

During an interview on 08/11/22 at 8:55 AM, Staff E, Director of Nursing (DON), presented the surveyors with a patient folder, which includes patient rights. Staff E stated that the folders are available, were located out back, and that the registration staff are just nervous.

During an interview on 08/11/22 at 9:13 AM, Staff S, Registrar, stated that she has worked for the ambulatory outpatient clinic for about 18 months. Staff S stated that she was provided a copy of patient rights to hang at her window. Staff S stated that if patients asked for a copy of their patient rights that she would not be able to provide them. Staff S stated that there is nowhere to document if patients received their rights. When Staff S was presented with the patient folder, Staff S stated that she has never been informed of or seen the patient folders. When Staff S was presented with the document, "Before and After Your Visit," she stated that she has never seen it before.

During an interview on 08/11/22 at 9:22 AM, Staff R, Registrar stated that she has worked at the hospital for about eight years and over a year at the ambulatory outpatient clinic. When Staff R was presented with the patient folder, she stated that she didn't know that the clinic had them. Staff R stated that patient rights are posted at each registrar's station.

During an interview on 08/12/22 at 11:35 AM, Staff M, Senior Director of Regulatory and Risk Management, stated that the ambulatory outpatient clinics does not have a method of ensuring the notice of patient rights.

During an interview on 08/12/22 at 11:40 AM, Staff M, Senior Director of Regulatory and Risk Management, Staff E, DON, and Staff C, ARC, were informed of and acknowledged the missing patients' rights.

Based on policy review, record review, document review, and interview, the hospital failed to ensure an effective operation of the grievance process regarding identification and resolution of grievances. This deficient practice led to a grievance going unidentified, uninvestigated, and unanswered for one known patient (Patient 2) and has the potential to affect all patients and may lead to harm or other adverse outcomes.

Findings Include:

Review of the Hospital's policy, "Management of Patient/Family Complaints and Grievances," approved 06/2021, showed "A grievance is considered as the following: a complaint that is not resolved at the time of the complaint by staff present; a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative about care or services; all written letters, e-mails or faxes from patients or their representatives, including written attachments to a patient satisfaction survey, or surveys with contents that will be handled as an unresolved complaint; all complaints alleging abuse, neglect, patient harm, or non-compliance with any Centers for Medicare and Medicaid Services requirements; any request by patients or their representatives that a complaint be handled as a grievance or formal complaint . . . grievances are to be resolved as soon as possible upon receipt by Patient Relations: i.e. within seven days . . . If patient's grievance cannot be resolved within seven days of Patient Relations' receipt of the grievance, a letter is to be sent to the patient or representative within this time frame with the purpose of acknowledging the grievance and indicating that appropriate follow-up will occur . . . send resolution letter to patient or patient's representative . . . a resolution letter is to contain the following information: name of the hospital contact person(s), steps taken on behalf of the patient to investigate the grievance, results of this process, and date of completion."

Review of Patient 2's medical record showed that Patient 2, a 77-year-old female, was seen in the ambulatory outpatient clinic on 08/03/22 at 10:46 AM for a lumbar transforaminal steroid injection (a spinal injection of an anti-inflammatory medication used for pain relief).

Review of Patient 2's "Progress Note," dated 08/03/22 at 11:32 AM, by Staff J, Registered Nurse (RN), showed, "[Patient 2] completed procedure at 10:55 [AM]. I attempted to assist pt [sic, patient] off procedure table in room 2 [two]. She was unsteady and weak. When trying to get her back onto the table, she slid down further. Unable to sustain herself, her legs gave way and she went on her knees. I then controlled her to the floor to get her legs out from under her. I called for help and staff came . . . and I [sic] were able to get her back to her wheelchair. Pt complained of pain in her left leg due to being bent awkwardly behind her. [Staff F, Medical Doctor (MD)] was contacted and came to see patient. He [Staff F] stated he wanted to make sure her vitals were stable and that she could stand on her own. We returned to the bay where vitals were taken. She was stable. [Staff] went to Physical Therapy and borrowed a walker so we could test if pt could stand. Pt was able to stand successfully, with two-person assist, on her own. Pt was able to sit down on her own without assist. Discharge orders were given and was d/c [discharged] from unit at 1125 [11:25 AM]. Will contact [Staff F, MD] to inform of results."

During an interview on 08/12/22 at 9:49 AM, Staff P, Manager of Patient Experience, stated that the Patient Relations Department handles all complaints and grievances and receives them from all sources and from anybody. Staff P stated that if the issue cannot be resolved in real time, by staff present, it is referred to her department and assigned to a specialist.

During an interview on 08/11/22 at 2:17 PM, Staff H, RN, Supervisor, stated that Patient 2's nursing home called on 08/03/22, between 4:30 PM and 5:00 PM, and informed her that Patient 2 wanted to file a complaint. Staff H told the nursing home staff that she would get with her supervisor, Staff N, RN Manager, in the morning [08/04/22]. Staff H stated that by the next morning when she went to speak with Staff N, Patient 2 was already admitted into the hospital.

Review of the Hospital's document, "Complaint and Grievance Log," for the previous 12 months showed that Patient 2's grievance, made on 08/03/22, was not acknowledged or logged for an investigation and resolution.

Based on policy review, document review and interview, the Hospital failed to ensure it provided patients or the patient's representative with a written notice of the grievance response containing the required regulatory elements for 4 of 15 grievances reviewed affecting Patients 3, 13, 14 and 16. This deficient practice has the potential to lead to unresolved issues and dissatisfaction for all patients involved.

Findings Include:

Review of the Hospital's policy, "Management of Patient/Family Complaints and Grievances," approved 06/2021, showed "A grievance is considered as the following: a complaint that is not resolved at the time of the complaint by staff present; a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative about care or services; all written letters, e-mails or faxes from patients or their representatives, including written attachments to a patient satisfaction survey, or surveys with contents that will be handled as an unresolved complaint; all complaints alleging abuse, neglect, patient harm, or non-compliance with any Centers for Medicare and Medicaid Services requirements; any request by patients or their representatives that a complaint be handled as a grievance or formal complaint . . . grievances are to be resolved as soon as possible upon receipt by Patient Relations: i.e. within seven days . . . If patient's grievance cannot be resolved within seven days of Patient Relations' receipt of the grievance, a letter is to be sent to the patient or representative within this time frame with the purpose of acknowledging the grievance and indicating that appropriate follow-up will occur . . . send resolution letter to patient or patient's representative . . . a resolution letter is to contain the following information: name of the hospital contact person(s), steps taken on behalf of the patient to investigate the grievance, results of this process, and date of completion."


Patient 3

Review of the Hospital's document titled, "Complaint and Grievance Log," for the previous 12 months showed that Patient 3's Durable Power of Attorney (DPOA), filed a grievance on 03/15/22, after a spine fusion procedure resulted in cement extravasation (leakage).

During an interview on 08/12/22 at 9:49 AM, Staff P, Manager of Patient Experience (MPE), stated that Patient 3's grievance process did not include a 7-day notification letter and that the grievance is not closed as of date of survey, 148 days from date the grievance was submitted. Staff P stated that the hospital did not provide the patient any notification to indicate how long the grievance process would take or that it would be extended past their 45-day process per their policy.


Patient 13

Review of the Hospital's document titled, "Complaint and Grievance Log," for the previous 12 months showed that Patient 13's insurance company filed a grievance on 08/12/21, stating that Patient 13 only received one of two injections ordered.

During an interview on 08/12/22 at 11:02 AM, Staff P, MPE, confirmed a resolution letter was not completed.


Patient 14

Review of the Hospital's document titled, "Complaint and Grievance Log," for the previous 12 months showed that Patient 14 submitted a grievance on 01/26/22, alleging that the incorrect procedure was performed and billed.

During an interview on 08/12/22 at 11:02 AM, Staff P, MPE, confirmed a resolution letter was not completed.


Patient 16

Review of the Hospital's document titled, "Complaint and Grievance Log," for the previous 12 months showed that Patient 16 submitted a grievance on 04/22/22. The column labeled description showed "pt [sic, patient] upset."

During an interview on 08/12/22 at 11:02 AM, Staff P, MPE, confirmed a resolution letter was not completed.


During an interview on 08/11/22 at 9:20 AM, Staff M, Sr Director of Regulatory and Risk Management, informed the surveyor that she was aware that not all of the grievances provided for review had acknowledgement or resolution letters.

Based on record review, policy review, interview, and observation, the Hospital failed to ensure staff followed its fall prevention policy to provide care in a safe setting for one of 10 patients reviewed (Patient 2) and failed to provide an assessment to identify an injury which resulted in Patient 2 requiring emergency treatment and hospitalization. This deficient practice has the potential to place all patients at risk for injury and harm.

Findings Include:

Review of the Hospital's policy titled, "Fall Prevention & Post-Fall management for Patient Care Areas," revised 09/2021, showed, " ...It is the philosophy of [the Hospital] to maintain patients' safety. This policy outline processes to prevent patient falls and injuries related to falls. The hospital assesses the patient's risk for falls based on the patient population and setting. The hospital implements interventions to reduce falls based on the patient's assessed risk and patient location within the Health System ...Patient are assessed by a licensed provider for risk of falls using standardized assessment tools based on population and setting: ...Ambulatory Care Areas: screening questions for ambulatory clinic patients. Procedural and Pre/Post areas: Pre-procedural locations will use appropriate fall risk screening tool based on patient's age. For pre-procedure patients identified as moderate or high fall risk, follow interventions in Appendix E. All patients receiving anesthesia and/or sedative medication in Perioperative or Procedural areas are considered to be high risk for falls ...All Employees maintain patient's safety by:

1. Having an overall awareness of patient fall risk and, as applicable, to take personal action to prevent patients from falls and injuries related to falls ...

...4. Maintain environmental safety for all patients ...

5. Ensure fall risk patients are accompanied by an employee and stay within arm's reach, when:
a. Ambulating in patient care areas, ensure hands are on patient/gait belt ...

Fall Prevention Interventions for patient populations and setting: ...

Appendix E: Procedural and Pre/Post areas: Procedural and Pre/Post areas: Pre-procedural locations will use appropriate fall risk screening tool based on patients age. All patients receiving anesthesia and/or sedative medication in Perioperative or Procedural areas are considered high risk for falls ...Post Fall Interventions: When a patient experiences a fall in the health system, follow the interventions outlined in Post-Fall Assessment Guidelines (Appendix I) ..."

Review of a document titled, "Appendix I: Post-Fall Assessment Guidelines for Inpatient Areas," showed "Immediate Post-Fall Assessment:

1. Stabilize the patient ...

2. Call for assistance, activate a response team if indicated and available ...

3. Immediate Interventions:
a. Check vital signs ...
b. Clean and dress any wounds
c. Assess for risk of injury using the following ABCS and report findings to physician during notification. The following groups of patients are most at risk for major injury, such as fracture or subdural hematoma, after they fall:
...i. Age: Individuals who are greater than or equal to 85 years old or frail to a clinical condition
ii. Bones: Patients with bone conditions, including osteoporosis, a previous fracture, prolonged steroid use, or metastatic bone cancer ...
d. Notify treating medical provider ...
e. Review current care plan and implement additional fall prevention strategies.

4. Continued Assessment ...

Post-Fall Communication: ...
...4. Notify family, provide fall prevention information to family and patient"

The Hospital failed to provide a policy for post fall assessments in any ambulatory or outpatient patient care areas of the hospital.


Patient 2

Review of Patient 2's medical record, "History and Physical," dated 06/28/22, showed a 77-year-old female that was referred the hospital's spine clinic for evaluation and treatment of lower back pain. Patient 2 had a medical history that included osteoarthritis (degeneration of joint cartilage and the underlying bone), breast cancer, gastroesophageal reflux disease (occurs when stomach acid repeatedly flows back into the esophagus), hyperlipidemia (an abnormally high concentration of fats in the blood), and hypertension (high blood pressure).


Review of a care plan dated 06/09/22, 06/11/22, 06/13/22 showed Patient 2 as a "High Fall Risk."


Review of Patient 2's "Health History Questionnaire," dated 06/27/22 at 3:33 PM showed that Patient 2 had two or more falls in the last year and a history of falls within the last six months, needed help every day in most aspects of self-care, could lift only very light weights, required assistive device for ambulation, and inability to stand for more than 10 minutes.


Review of the medical record showed on 08/03/22, Patient 2 had a transforaminal epidural (a spinal injection of an anti-inflammatory medication used for pain relief) performed by Staff F, MD in the ambulatory/outpatient spine clinic.


Review of a flow sheet dated 08/03/22 at 10:17 AM, showed Patient 2's height as 5' 7" and weight 207 pounds. Patient mode of transportation pre-procedure was documented as a wheelchair. Patient 2 was taken to the procedure room at 10:45 AM, procedure start time was recorded at 10:52 AM, procedure end time was recorded at 10:55 AM, and time removed from procedure room was recorded at 11:13 AM. A pre-procedural pain assessment documented by Staff I, Registered Nurse, (RN) at 10:18 AM showed a pain rating of 0/10. Transfer/Discharge Report Information, recorded by Staff I, RN at 11:52 AM showed mode of transport as a wheelchair, discharged to home, time left unit 11:25 AM. The medical record failed to show evidence of a documented post-procedural or discharge pain assessment.


Review of a note titled "Other Progress Notes," documented by Staff I, RN, dated 08/03/22 at 11:32 AM, showed, "PT (patient) completed procedure at 1055 (10:55 AM). I attempted to assist pt (patient) off procedure table in room 2. She was unsteady and weak. When trying to get her back onto the table, she slid down further. Unable to sustain herself, her legs gave way and she went on her knees. I then controlled her to the floor to get her legs out from under her. I called for help and staff came. [Staff H] RN, [Staff K] RN, [Staff L, Support Tech] and I were able to get her back to her wheelchair. Pt (patient) complained of pain in her left leg due to being bent awkwardly behind her. [Staff F, MD] was contacted and came to see patient. He stated he wanted to make sure her vitals were stable and that she could stand on her own. We returned to the bay where vitals were taken. She was stable. [Staff G] RN, went to Physical Therapy and borrowed a walker so we could test if pt (patient) could stand. Pt (patient) was able to stand successfully, with two-person assist. Pt (patient) was able to sit down on her own without assist. Discharge orders were given and was d/c (discharged) from unit at 1125 (11:25 AM). Will contact [Staff F, MD] to inform of results."


Review of a medical record from Hospital 2 [H2] showed Patient 2 arrived at the Emergency Department (ED) by private vehicle with a chief complaint of rib pain. An ED Provider Assessment showed, "First Contact with Patient 17:21 (5:21 PM), 08-03-2022 ...Patient presents to the emergency department due to right rib pain. Patient reports that she had a procedure done at [H1] today she felt like they did not have a hold of her and that her body weight was placed on most of her rib cage creating her right rib pain. Patient reports pain is on the anterior rib underneath breast. Patient has small red ecchymosis (bruising) underneath right breast ..."


Review of an H2 nursing assessment, "ER Initial Assessment," dated 08/03/22 at 5:22 PM, showed, "Pt (patient) to ED with husband. Reports that she had back injections at [H1] today and when they were getting back to the w/c (wheelchair), she reports that they dropped her. Staff there said that they lowered her to the floor. She is c/o (complaint of) right rib pain. bruise noted to upper abdomen ..."


Review of an H2 provider note, dated 08/04/22 at 12:18 AM, showed, " ...1915 (7:15 PM): noted a pneumoperitoneum (presence of air or gas in the abdominal cavity) that was visible on CXR (chest x-ray)..2315 (11:15 PM): CT (computed tomography scan used to obtain detailed internal images of the body) with large amount of intraperitoneal free air suggesting perforated viscus (a life-threatening condition that occurs when the wall of the gastrointestinal tract ruptures and the contents leak into the space between the abdominal wall and the internal organs). Acute right 9th anterior rib fracture with irregularities of the left 5th through 8th anterior ribs - possible nondisplaced fractures and a few mildly distended small bowel loops. 2325 (11:25 PM): [H1] transfer line contacted to transfer patient - this is where she had her procedure completed today with subsequent fall. 2349 (11:49 PM): Received call from [H2] transfer line accepting patient - will go to SICU (Surgical Intensive Care Unit) with plans for OR (Operating Room) tonight ..."

Review of Patient 2's medical record showed that Patient 2 was accepted for transfer from H2 via ambulance on 08/04/22 to H1.


Review of Patient 2's medical record from H1 showed the following:

A Provider Progress Note dated 08/04/22, showed, "HPI: [Patient 2] is a 77 y.o. female ...transferred from [H2] for pneumoperitoneum and rib fractures. She underwent a spinal injection today and had a fall post procedure. She began having back pain, chest pain, and subsequent minimal abdominal pain. She then presented to [H2] and CT imaging demonstrated pneumoperitoneum and rib fractures. She states the pain in her lower abdomen has continued to worsen ..."


Review of a General Inpatient Consult Note dated 08/04/22, showed, "Patient 2 is a 77 y.o. female ... who is admitted after a fall, complicated by rib fractures and pneumoperitoneum ... [Patient 2] reports that yesterday after a pain procedure she was being assisted off the bed when she abruptly fell to the ground. She notes her rib caught on the bed and she had abrupt onset of chest pain. She was then brought to [the Hospital] emergently as a CT scan of her abdomen reveals intraperitoneal air. In the OR her bowel was run, did not show any sign of tear or explanation for the free air ..."


Review of a Provider Progress Note dated 08/05/22, showed " ...Assessment/ Plan: Method of injury: [Patient 2] is a 77 y.o. female ... transferred from [H2] for pneumoperitoneum and rib fractures. She underwent a spinal injection 8/3/22 and had a fall post procedure. She began having back pain, chest pain, and subsequent minimal abdominal pain. She then presented to [H2] and CT imaging demonstrated pneumoperitoneum, acute vs chronic anterior vertebral body at L4 and rib fractures. She was taken to OR for exlap (exploratory laparotomy, a type of major surgery that involves opening the abdomen with a large incision in order to visualize the entire abdominal cavity) which was negative. She remained medically stable and was transferred to the floor. Medically stable for discharge back to her facility 8/5 ..."


During an interview on 08/11/22 at 9:53 AM, Patient 2 stated that she went in for a spinal injection with Staff F, MD. Her husband accompanied her to the appointment but waited in the reception area. Patient 2 was taken to what she described as a "cubby area" to be prepped and then taken to the procedure room. She stated that she was not able to use the step stool to get onto the procedural table and required two people ("two young men") to assist getting onto the table, she stated that they swung her legs around and laid her face down on the table. Patient 2 stated that after the procedure Staff I, RN said, "I'll slide you off the table until your feet are on the floor." Patient 2 stated that she asked if there was anyone else to help with transferring her and he said something like, "No, I've got you." Patient 2 stated that he started to slide her off the procedure table when her legs gave out and she stated that she got "hung up" on the table between the mattress and the metal edge, on her right-side rib area. Patient 2 stated, "My left leg bent out and backwards." She stated that at that time Staff I, RN yelled out for help. "He left me at the table and went to the door to call for help. I was still hung up on the table. He came back and set me on the floor." Patient 2 stated that she was crying and had pain in her rib area. Patient 2 stated, "[Staff I, RN] said he lowered me to the floor. I say I fell off the table." She stated that when finally lowered to the floor after calling for help, Staff I, RN laid her out flat on her back on the floor. Other staff arrived and four people picked her up, two at her arms, two at her legs, and placed her into the wheelchair. Patient 2 stated, "Not sure when [Staff F, MD] came in but he was in the room and just stood in the doorway. Didn't examine me. Nobody examined me. Didn't ask about pain. Nobody asked me about pain. Took me back to a cubicle. Was told I could leave when I could stand and walk. They wheeled me out to my husband." Patient 2 stated Staff I, RN apologized and said, "Sorry, it was my fault," and kept apologizing several times.

Patient 2 stated that she did not inform the staff that she was hurting and did not say anything about her rib pain because, "I just wanted to get home." She stated that the clinic staff did not inform her husband of the fall because they thought he was a contracted transportation employee.

Patient 2 stated that once she was discharged, she was transported to her place of residence (nursing home) and arrived at approximately 1:30-2:00 PM. She stated that she immediately informed the RN at her facility of the fall and was assessed. The RN noted bruising on her right side and called the clinic.

Patient 2 stated, "About 5:00 PM, I told the nurse I was in pain. They took me to the local hospital (H2). They did an x-ray and gave me pain medication. A CT scan found pockets of air in my abdominal cavity. Decided to send me back to [H1] by ambulance about 1:00 AM and got to [H1] about 3:00 AM on 08/04/22."


During the interview Patient 2 stated that when she arrive at H1, they did immediate surgery and couldn't determine where the air came from. Patient 2 stated that she had about a 15-inch incision and fractured ribs. Patient 2 stated that she was discharged from the H1 about 11:30 AM on 08/05/22.


During an interview on 08/10/22 at 3:00 PM, Staff J, Clinical Supervisor, stated during Patient 2's chart review that Staff F, MD did not document anything in the medical record about the patient's fall. She stated during record review that Patient 2 had a documented history of two or more falls in the past six months.


During an interview on 08/10/22 at 3:00 PM, Staff H, Registered Nurse (RN), stated that in case of a patient fall the doctor is notified and a safety intelligence report is completed. Vitals and an assessment are to be completed. She stated that on 08/03/22, Staff F, MD was notified of Patient 2's fall. He came and visited with the patient to see if she was ok to go home. She stated that staff was most concerned if patient was having pain in her back because of her recent surgery. When [Staff F, MD] assessed her, she was asked where her pain was, and she was mainly complaining of pain in her legs. She stated that Staff I, RN witnessed Patient 2's fall and completed a head to toe assessment. When asked if the head to toe assessment included a skin assessment, Staff H stated that Patient 2 was wearing shorts therefore her legs were assessed, but a skin assessment of her torso was not completed, and that Patient 2 was not palpated anywhere to check for pain/tenderness.


During an interview on 08/11/22 at 12:22 PM, Staff K, RN stated that she received a call for help in the procedure area Room 2, Patient 2 was sitting on the floor with her legs extended when she arrived. She stated that Patient 2 was upset and in pain. Staff K stated, "I think she said the pain was in her side, but I don't remember everywhere she said she was in pain. No visible injury noted." She stated that Staff I, RN, Staff H, RN, and somebody else, who she couldn't remember, all grabbed a leg or under arm pit and picked her up and put her in the wheelchair. Staff K stated "I did not see anyone do vitals but don't know what was done before I got there. I did not see [Staff F, MD] come in the procedure room. [Staff I, RN] was talking to the patient after getting her into the wheelchair but I did not witness a physical assessment. I was no longer needed after getting patient to wheelchair so left the area."


During an interview on 08/11/22 at 12:36 PM, Staff L, Support Technician, stated, "I can't say a lot about the incident. I was the one to take her to the procedure room, wheeled her in by wheelchair, nurse would go in to take vitals, etc. I was in the recovery bay area when the incident happened. The fall happened after her procedure. [Staff G, RN] was walking to go help with the fall and asked me to go assist. The patient was on the ground, sitting up, [Staff I, RN] was in front of her talking to see if things were ok. She appeared panicked instead of in pain. She didn't specify anything that was major, so we did a 4 person lift to get her back in the chair. She did not say she was hurting. She said she "tweaked her leg a little bit" but nothing that was keeping her immobile. I did not see [Staff I, RN] get a set of vitals before she was moved from the floor."


During an interview on 08/11/22 at 12:54 PM, Staff I, RN stated that Patient 2 was taken back to procedure room 2 and that he and another staff member assisted with getting Patient 2 onto the table. Staff I, RN, stated, " ...I got the wheelchair positioned close to the table and asked her to swivel her legs which she did. She got nervous and began to slide. She was holding onto the table still, so she was not completely on the ground. She (the patient) said, "I should have told you to get 2 people..." Staff I Staff I, RN confirmed that he had not checked Patient 2's fall risk status prior to transferring and that Patient 2 should have required a two person assist for transfer. Staff I, RN stated that he called out for help but got no response. He then helped Patient 2 to the floor and straightened her legs. After assisting Patient 2 to the floor he placed a phone call for assistance. Staff I stated that Patient 2 was crying and complained of left knee pain. He stated that there was no visible injury and Patient 2 had mobility in her left leg. Once additional staff arrived, Patient 2 was placed in the wheelchair and vitals were assessed. Staff I, RN stated, " ...She was still weeping a little bit and I apologized profusely to her ... [Staff F, MD] did not do any type of assessment ..." Staff I, RN stated that Patient 2 was given an ice pack for her left leg with instructions on use. No other discharge instructions were given on post procedure care or fall/injury education or precautions.


During an observation on 08/11/22 at 2:50 PM, Staff I, RN, demonstrated how Patient 2 fell from the procedure table. The procedure table was a metal bed with an approximately 1.5-inch-thick pad. Staff I, RN, laid on the table face down. While demonstrating, Staff I, RN stated that Patient 2's left leg left the table first. This momentum caused Patient 2's left hip to slip off the table and that Patient 2 could not stop the movement and her right leg also started to fall off the table. Staff I, RN stated that he placed his right knee and leg against Patient 2, applying pressure to her against the table to hold Patient 2 and prevent her from falling to the floor. Staff I, RN stated that Patient 2 held onto the table with her arms but could not get her feet under her. Staff I, RN stated that he attempted to call for help, but nobody came. Staff I, RN lowered Patient 2 to the floor where her left knee bent under her and her buttocks sat on the ground. Once on the ground Staff I, RN stated he helped straighten Patient 2's legs out in front of her.


During an interview on 08/11/22 at 2:05 PM, Staff H, RN, stated that on 08/03/22, when she arrived to help, Patient 2 was sitting on the floor with her back to the door and her legs extended. Staff H, RN stated that Patient 2 was crying and complained of leg pain. She stated that nursing did not complete a head to toe physical assessment and that Staff F, MD, did not do a physical assessment on Patient 2. Staff H, RN, stated that Patient 2 did not received pain medication but was given an ice pack with instructions for use.


During an interview on 08/11/22 at 4:08 PM, Staff F, MD stated that he arrived after Patient 2's fall and did not witness her on the floor or how her care was managed prior to his arrival. He stated that Patient 2 did not voice pain related to the fall and stated, "In my mind there were no concerns ..." Staff F, MD stated that after a fall, a history and physical exam should be done to determine if any additional treatment is needed and stated, "which I did."