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Based on medical record review, document review, interview, and observation, the facility failed to ensure compliance with the Condition of Participation of Emergency Services. Specifically, the facility failed to implement fall prevention interventions in the emergency department (ED) for 4 patients who had been identified as being at high risk for falls. (Patient #2, Patient #3, Patient #4, and Patient #5). The hospital's policy and procedure failed to specify what fall prevention interventions should be implemented in the ED based on results of the "Memorial Emergency Department Fall Risk Assessment," (MEDFRAT- tool used in EDs to identify patients at high risk for falls) which must be completed on every adult patient (18 years or older) who is admitted to the ED. Failing to implement measures to prevent falls in the ED places patients at risk for falls.

Findings include:

-- Hospital staff failed to implement fall precautions, after recognizing a patients (Patient #2) high risk for falls.

-- Hospital staff failed to implement fall precautions for 3 additional patients (Patient #3, Patient #4, and Patient #5) in the ED. Each of these patients had been identified by their assigned registered nurse (RN) as being at high risk for falls.

-- Review of the facility's policy and procedure titled "Inpatient Fall Management," revised 5/19/2023, revealed that it does not specify what fall prevention interventions should be implemented after an RN completes the MEDFRAT to evaluate the fall risk of a patient n the ED.

See Tag A1104.

Based on document review and interview, in 1 of 1 hospital investigations reviewed, it was determined that the hospital did not identify all contributing factors that impacted this event.

Findings include:

-- Review of the hospital's policy and procedure titled "Safety Event Reporting," revised 10/2022, indicated each event will be investigated and corrective actions will be implemented by the responsible department when indicated.

-- Review of a hospital's investigation report,(undated), indicated a patient had an adverse event. The report identified one contributing factor to the event. Additional contributing factors were not identified and therefore staff were not provided with education to prevent a similar event.

-- Per interview of Staff B, CT Technician, on 9/17/2024 at 10:00 am, in this event, the involved patient was not wearing a red bracelet to indicate they were at high risk to fall and they were not provided report regarding the patient's mobility.

-- Per interview of Staff A, Patient Safety Officer, on 9/20/2024 at 4:30 pm (and at other times throughout the survey), they confirmed no action was taken to provide education to nursing staff about fall prevention interventions in response to this investigation.

Based on medical record review, document review, observation, and interview 1) in 1 of 21 (Patient #2) medical records reviewed, hospital staff failed to implement fall prevention interventions to prevent the patient from falling in the emergency department (ED), 2) in 3 of 3 (Patient #3, Patient #4, and Patient #5) observations, hospital staff failed to implement fall prevention interventions, and 3) the hospital's policy and procedure failed to specify what fall prevention interventions should be implemented in the ED, based on results of the required fall risk assessment. This contributed to a patient fall in the ED.

Findings for (1) include:

-- Per medical record review, on 7/11/2024 at 11:59 pm Patient #2 presented to the ED via ambulance with a chief complaint of altered mental status. Family reported history of high ammonia levels and similar episodes of altered mental status as a result in the past. The patient takes Lactulose (a medication used to reduce the amount of ammonia in the blood of patients with liver disease) three times a day as treatment for cirrhosis (scarring of the liver that causes it to fail). Registered nurse (RN) documented patient was confused, disoriented, and appeared distressed. Behavior was agitated and uncooperative. Patient was unable to answer questions. Vital signs (vs) were blood pressure (BP) 116/78, Pulse (P) 93, Respirations (R) 20, temperature (T) 97.8 degrees, oxygen saturation 98% on room air.

On 7/12/2024 ED Physician Record (no time indicated) revealed: Chief Complaint: decreased mental status, confused. History obtained from significant other who noted patient was difficult to awaken and confused this morning. At baseline, patient is alert and oriented and walks without assistance. Past medical history includes cirrhosis of liver. Physical exam: lethargic, not speaking, thrashing around. Moving all four extremities, unable to assess strength, sensation, or weakness as patient unable to comply with neurological exam due to confusion. Wounds on both feet. Chest x-ray normal. Electrocardiogram (EKG) normal. Clinical impression: Hepatic Encephalopathy (loss of brain function when damaged liver doesn't remove toxins, including ammonia, from the blood) with high ammonia level. Patient admitted.

7/12/2024 at 12:41 am: Registered nurse documented neurological assessment: Altered mentation, confused, arousable to name, but unable to evaluate comprehension. Unable to maintain eye contact. No facial droop. Behavior is restless. Glasgow Coma Scale (GCS) was 10 (tool used to score level of consciousness based on eye response, verbal response, and motor response. Scores range from 3 to 15 with a higher score indicating higher level of consciousness).

"Memorial Emergency Department Fall Risk Assessment Tool" (MEDFRAT) [fall risk assessment tool used to evaluate an ED patient's risk for falls] fall risk assessment: RN entered "yes" to indicate patient was confused/disoriented, intoxicated or sedated, and had impaired gait. RN documented "no" mobility assistance devices used, no alterations in elimination. Unable to assess fall history at this time. Fall risk score of 14; Fall risk indicators documented as "high". Fall prevention interventions: Bed in low position, siderails up, call light in reach, and non-skid-footwear. (Note: These are universal fall prevention interventions according to hospital, Fall Prevention Program education)

7/12/2024 at 3:20 am: Registered nurse documented reassessment, patient was alert to name, but remains unable to answer basic orientation questions or follow commands.

7/12/2024 at 4:35 am: Computed tomography (CT) scan of head ordered: Reason for exam was altered mental status. Computed tomography scan of abdomen and pelvis ordered: Reason for exam was altered mental status and loose stool. Physician indicated transport by stretcher as patient is unable to stand without assistance.

7/12/2024 at 4:39 am: Registered nurse entered order for Fall Precautions.

7/12/2024 at 5:55 am: Admission History and Physical (in part): Patient is a 68-year-old with known nonalcoholic cirrhosis who was brought to the ED for altered mental status. Husband noted patient's behavior was not at baseline earlier and realized Lactulose had not been taken in several days. Patient was awake but confused, unable to respond to questions with appropriate responses. Past medical history: Cirrhosis with history of hepatic encephalopathy, chronic thrombocytopenia (low platelets due to liver disease, leads to increased risk for bruising and bleeding), chronic lower back pain with severe peripheral neuropathy (weakness, numbness, and nerve pain, often affecting hands and feet). Abnormal findings from exam: awake, but restless, inattentive, shuffling in bed, not following commands, sleepy. Neuro status: awake, speaks one word from time to time, not answering questions.

7/12/2024 at 5:55 am: Registered nurse documented patient remained anxious and restless. Patient extremely confused. Patient attempting to get out of bed frequently and had to be redirected to expel fluids while in bed. Emergency department assistant (EDA) at bedside with patient for safety.

7/12/2024 at 6:59 am: Registered nurse documented patient calm and resting. Emergency department assistant relieved from sitting with patient.

7/12/2024 at 7:42 am: Registered nurse documented altered mental status continued. When asked name and date of birth, patient only provided date of birth. Patient went to have CT and fell while tech was moving the ED stretcher away from the CT table. Patient rolled off, approximately 2 feet, on to right side. Patient did not strike head or lose consciousness. Physician notified of fall and mental status exam.

7/12/2024 at 7:51 am: Computed tomography scan of spine ordered: Reason for exam was fall, new complaint of neck pain. Rule out fracture. 7/12/2024 at 8:16 am: VS: BP 187/77, P 97, oxygen 99%.

-- Per review of the facility's policy and procedure titled "Inpatient Fall Management," revised 5/19/2023, upon admission to the ED and/or all inpatient units, a RN will conduct a fall risk assessment on each patient ... All fall precaution interventions, as determined by the level of fall risk and individual needs, must be implemented ... In the ED, the MEDFRAT fall risk assessment must be completed on every adult patient (18 years or older) who is admitted to the ED.

The hospital's policy and procedure lists does not list fall prevention interventions that correspond to the scores for the MEDFRAT, which is used to categorize patients' fall risk in the ED setting.

-- Per interview of Staff B, CT Technician, on 9/17/2024 at 10:00 am, Patient #2 was not wearing a red bracelet to indicate they were at high risk to fall. Typically, RNs give report and/or help transport, but they were not available to do so for this patient.

--Per interview with Staff C, Chief Nursing Officer, on 9/27/2024 at 10:15 am (and at other times during the survey), they acknowledged these findings.

Findings for (2) include:

-- During observation of Staff D, ED RN, at 9:50 am on 9/27/2024, they transported a patient (Patient #3) with altered mental status from the CT scanner to their room in ED. The patient was noted not to be wearing a falls risk bracelet.

-- Per interview of Staff D, at 9:55 am on 9/27/2024 , Patient #3 was at high risk for falls as they presented to the ED (within the prior 45 minutes) with neurological changes that indicated possible stroke. Staff D indicated fall prevention interventions should be implemented once a patient has been identified as at high risk for falls, however, they prioritized the patient's diagnostic work up. With the need for urgent imaging, fall precaution interventions had not yet been fully implemented. Staff D indicated their patient assignment included three other ED patients: 2 of these 3 patients (Patient #4 and Patient #5) were identified as being at high risk for falls, 1 of the 3 patients was at low risk for falls.

-- Per interview of Staff A, Patient Safety Officer, on 9/20/2024 at 4:30 pm (and at other times throughout the survey), Staff A acknowledged the hospital's policy and procedure does not specify which fall prevention interventions correspond to the scores for the MEDFRAT, which is the fall risk assessment used by RNs in the ED. Staff A acknowledged, like the hospital's policy and procedure, the fall prevention education, which all staff complete, describes only interventions which correspond with the results of the MORSE and Humpty Dumpty fall risk assessments. Staff A confirmed there is no separate education that addresses fall prevention interventions in response to the patient's risk score as determined by the MEDFRAT. Staff A indicated that ED staff should be putting fall prevention interventions in place for patients who are, based on the MEDFRAT fall risk assessment, at high risk for falls. Fall prevention interventions for patients at high risk to fall include using fall risk bracelets, non-slip socks, and indicating with signage, on the patient's door and at the head of the bed, that they are at high risk to fall (among others as appropriate to individual patients). These interventions should be chosen from drop down choices within the medical record to document which fall prevention interventions were put in place by ED staff. Staff A acknowledged this could lead to patients without appropriate fall prevention measures in place in the ED.

-- Per observations in the ED, between 9:50 am and 10:45 am, 2 patients (Patient #4 and Patient #5), who were identified as being at high risk for falls by Staff D, lacked appropriate fall prevention interventions. Neither patient's door had any indication (i.e., signage, magnet, or sticker) that would alert staff of their high risk for falls. Neither patient was wearing a fall risk bracelet or non-slip socks.

-- Per interview of Staff C, on 9/27/2024 at 9:55 am, they indicated additional fall prevention interventions should have been implemented, in addition to the standard fall prevention interventions, due to the patients' high fall risk. Staff C acknowledged the above findings.

Findings for (3) include:

-- Review of the facility's policy and procedure titled "Inpatient Fall Management," revised 5/19/2023, indicated "the purpose of the policy is to provide guidance to hospital staff on how to prevent falls, to reduce potential for patient injury from a fall, and to provide the framework for assessing risk factors for falls, implementing interventions for reducing the risk for falling, and protecting patients from injury if a fall should occur. Fall prevention procedures are based on the assessment of the patient, determination of the patient's risk for fall, and implementation of interventions that reduce the intrinsic and extrinsic risks identified ... Upon admission to the ED and/or all inpatient units, a RN will conduct a fall risk assessment on each patient using the electronic medical record. All fall precaution interventions, as determined by the level of fall risk and individual needs, must be implemented. ... In the ED, the MEDFRAT fall risk assessment must be completed on every adult patient who is admitted to the ED. On the inpatient units, the MORSE fall risk assessment must be completed by a RN on every adult patient admitted to an inpatient unit; the level of fall risk is determined by the patient's MORSE score. The Humpty Dumpty fall risk assessment is used for pediatric patients (less than 18 years old). Universal Fall precautions education and interventions apply to all patients. "

The hospital's policy and procedure lists specific fall prevention interventions that should be implemented based on results (the numerical score) of the MORSE and Humpty Dumpty fall risk assessments, but does not specify which fall prevention interventions correspond to the scores/risk categories that are derived from for the MEDFRAT fall risk assessment, which is used to categorize patient's fall risk in the ED setting.

-- Per review of "Fall Prevention Program," revised 3/2023, which outlines the content of the mandatory annual staff training, "the Fall Prevention Program is hospital wide. All employees are responsible for identifying risk factors in the facility and must implement Universal fall Precautions in their respective work areas."

The hospital's training lists specific fall prevention interventions that should be implemented based on results (the numerical score) of the MORSE and Humpty Dumpty fall risk assessments but does not specify which fall prevention interventions correspond to the scores/risk categories that are derived from for the MEDFRAT fall risk assessment, which is used to categorize patient's fall risk in the ED setting.

-- During interview of Staff C, Chief Nursing Officer, on 9/27/2024 at 4:30 pm (and at other times throughout the survey) they indicated the falls education does not specify which interventions correspond to risk categories that are determined by the ED patient's score on the MEDFRAT. Staff C indicated that there is not a separate educational program for ED staff that addresses fall prevention interventions. Staff C acknowledged this could lead to inconsistent implementation of fall precautions and fall prevention interventions within the ED. Staff C acknowledged the above findings.