HospitalInspections.org

Based upon interview and record review, the facility failed to ensure 1 patient [Pt. #1] of 10 sampled patients received care in a safe setting after identifying the patient as a high risk for falls.
Findings include:
Per record review, Patient #1 was admitted to the facility's Emergency Department [ED] on 2/3/22 after suffering a fall at an Assisted Living Facility nearby. The ED triage notes record the patient had fallen 2 weeks prior to this fall and was complaining of hip pain. The ED notes state the patient "is a poor historian, history of dementia." Triage notes list 'Active Problems' which include "back pain", "balance problem", "memory deficit", and "myoclonic disorder [ sudden, brief, involuntary muscle jerks]".
Review of Pt. #1's 'Admission History', dated 2/3/22 reveals the patient was assessed as having a 'hearing deficit' and 'memory problems' identified as 'barriers to learning'.
Under the heading 'Patient Safety', interventions checked off as implemented include 'adequate room lighting', 'bed in low position', 'ID band check', 'personal items within reach', and 'side rails up X 2'.
Under 'Patient Safety' on Pt.#1's Admission History, interventions available but not checked off as implemented include 'bed alarm on', 'call device within reach', 'chair alarm on', 'non-slip footwear', 'patient positioned near nursing station', and 'personal alarm on'.
Additional areas in the patient's Admission History form include 'Room orientation/facility policy reviewed' with yes/no response left blank, along with the section 'Reason room/facility orientation not reviewed' also left blank. A section labeled 'Demonstrates ability to use call light successfully', with yes/no response is also left blank.
Review of Physician Notes on 2/3/22 reveal Pt. #1 "sustained a fall in the emergency department, having climbed out of bed. This was heard by the coordinator and myself; I immediately evaluated the patient, finding a laceration of [h/her] right eyebrow, small laceration on [h/her] left elbow, and a very small/superficial skin tear on [h/her] left shin. [H/she] had some swelling on [h/her] left hand as well ... [h/she] was noted to have a sizable hematoma (also called a contusion or bruise) around [h/her] right eye ... I sutured [h/her] eyebrow, applied a Steri-Strip to [h/her] elbow, and a Band-Aid to [h/her] shin after cleaning the wounds thoroughly ... Given [h/her] repeat fall, I believe [h/she] would benefit from admission."
An interview was conducted with an ED Staff member, the Chief Medical Officer [CMO], and the Director of Risk Management and Infection Prevention [DRMIP]on 5/31/22 at 4:00 PM.
The ED staff member reported that because Pt. #1 was admitted to the ED with a fall, h/she was assessed as and identified as a "high risk" for falls. The ED staff member stated that because Pt. #1 was a "high risk", fall prevention interventions such as anti-slip footwear and bed and/or chair alarms would be implemented to promote greater patient safety.
The ED staff member, CMO, and DRMIP confirmed that interventions to prevent falls and promote patient safety for Pt. #1, who was identified as a high risk for falls, were not implemented, and that the patient suffered a fall with injury while in the facility's Emergency Department.