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Based on medical record review and physician and staff interview, facility staff failed to monitor a patient in a bathroom, resulting in a fall in 1 of 2 (Patient #7) who fell in the emergency department.

Findings included:

Closed medical record review of Patient #7 revealed a 92-year-old female who presented to Hospital A's main campus' emergency department on 03/12/2018 at 0858 with a chief complaint of slurred speech, and per family report, shortness of breath on the previous day. Review of a nurse's note written on 03/12/2018 at 1450 by Registered Nurse (RN) #1 revealed, "Pt walked to restroom with steady gait with standby assist by RN. Pt instructed to pull alarm when finished or if she needed help." Review of a nurse's note written on 03/12/2018 at 1450 by RN #2 revealed, "Pt found face down in floor of bathroom with both legs on side of toilet. Maintaining c-spine. Pt logrolled to bb (backboard) and placed on stretcher with (Named Medical Doctor [MD] #1) at bedside. Pt noted as unresponsive to verbal or stimuli (sic)." Review of an ED Provider note written by MD #1 on 03/12/2018 at 1652 revealed, "Labs without significant findings. CT with concern for mass but MRI showed a meningioma. Patient got up to go to the bathroom. In the bathroom unattended she had a syncopal event and was found on the floor ..."

Telephone interview conducted with MD #1 on 04/18/2018 at 1415 revealed MD #1 was comfortable with Patient #7 walking to the bathroom with assistance, as she was ambulatory prior to her arrival to the emergency department. Interview revealed MD #1 felt Patient #7 should not have been left unattended in the bathroom.

Interview conducted with RN #1 on 04/18/2018 at 1544 revealed RN #1 was not Patient #7's primary RN. Interview revealed MD #1 stopped RN #1 in the hall and asked for Patient #7 to be escorted to the restroom to obtain a urine sample as the lab sample had been pending for several hours. Interview revealed Patient #7 insisted to be allowed to walk to the restroom, and the patient had on grip socks, and RN #1 escorted her to the restroom. Interview revealed RN #1 did not recall any family member asking for the patient to be accompanied in the restroom. Interview revealed RN #1 informed an ED Tech that was working near the restroom Patient #7 was there, and returned to her assigned area, because she (RN #1) had blood to draw from another patient.

Interview conducted with the ED Tech on 04/18/2018 at 1610 revealed she was assisting another RN when RN #1 informed her Patient #7 was in the restroom. Interview revealed she was not actively guarding the restroom. Interview revealed when her task was complete she went to the restroom to check on Patient #7 and found her on the restroom floor, and immediately called for help, to which facility staff immediately responded. Interview revealed Patient #7 was not in the restroom for "a minute" before she (the ED Tech) went to check on the patient.

NC00137715