HospitalInspections.org

Based on hospital policy review, medical record reviews, and staff interviews the hospital's nursing staff failed to assess patients for high risk of falls for 9 of 27 emergency department (ED) records reviewed (#5, #1, #2, #6, #16, #19, #20, #22, and #25).

The findings include

Review on 06/26/2013 of hospital policy CS 05 "Fall Prevention Policy" effective April 19, 2011 revealed "POLICY STATEMENT: All adult inpatients will be assessed for fall risk using the Hendrich II fall risk assessment model. Fall risk will be evaluated upon admission, once every shift thereafter, and as necessary with any change in condition. All patients identified as being at high risk for falls....., will be placed on the fall prevention protocol. Safety strategies for all patients will be utilized and implemented as appropriate. ..."

Interview on 06/26/2013 at 1310 with the Senior Director of Clinical Services revealed Policy CS 05 applies to the hospital's inpatient units only. Interview revealed the policy does not apply to the ED. Interview revealed "the ED had a falls policy at one time but that policy was retired." Further interview revealed nursing leadership "talked about the ED going to the new falls prevention policy that the inpatient units use but the policy needed verbiage changes to cover the ED as well as the inpatient units. The ED also uses the Morse Fall score instead of the Hendrich II and the policy needed to be changed to reflect the use of the Morse fall score." Interview revealed "the practice" is for nursing staff to perform a falls risk assessment on all patients who present to the ED. Interview revealed "at this time there is no formal policy." Interview revealed the "expectation" is for a falls risk assessment to be performed on all ED patients and interventions implemented as indicated. Interview revealed "at this point there is no policy for the ED to follow."

1. Closed ED record review on 06/26/2013 for Patient #5 revealed a 95 year old male who presented to the hospital's ED on 06/14/2013 at 0236 with complaints of an injury to the right hip secondary to a fall. Review revealed the patient was diagnosed with a proximal femur fracture and fall. The patient was transferred to another acute care hospital at 0648. Record review failed to reveal any available documentation a falls risk assessment was performed by nursing staff while the patient was in the ED.

Interview on 06/27/2013 at 1025 with the Senior Director of Clinical Services confirmed no documented evidence of a falls risk assessment was performed on Patient #5 while in the ED.

2. Closed ED record review on 06/26/2013 for Patient #1 revealed a 29 year old male who presented to the hospital's ED on 06/02/2013 at 1057 with complaints of an injury to the right knee secondary to a fall. Review revealed the patient was diagnosed with a sprained right knee and contusion to right knee. The patient was discharged at 1220. Record review failed to reveal any available documentation a falls risk assessment was performed by nursing staff while the patient was in the ED.

Interview on 06/27/2013 at 1025 with the Senior Director of Clinical Services confirmed no documented evidence of a falls risk assessment was performed on Patient #1 while in the ED.

3. Closed ED record review on 06/26/2013 for Patient #2 revealed a 71 year old male who presented to the hospital's ED on 06/02/2013 at 1343 with complaints of an injury to the left ankle. Review revealed the patient was diagnosed with a fractured left fibula. The patient was discharged at 1512. Record review failed to reveal any available documentation a falls risk assessment was performed by nursing staff while the patient was in the ED.

Interview on 06/27/2013 at 1025 with the Senior Director of Clinical Services confirmed no documented evidence of a falls risk assessment was performed on Patient #2 while in the ED.

4. Closed ED record review on 06/26/2013 for Patient #6 revealed a 72 year old male who presented to the hospital's ED on 05/12/2013 at 1448 with complaints of knee pain and swelling. Review revealed the patient was diagnosed with a joint effusion right knee. The patient was discharged at 1703. Record review failed to reveal any available documentation a falls risk assessment was performed by nursing staff while the patient was in the ED.

Interview on 06/27/2013 at 1025 with the Senior Director of Clinical Services confirmed no documented evidence of a falls risk assessment was performed on Patient #6 while in the ED.

5. Closed ED record review on 06/26/2013 for Patient #16 revealed a 27 year old male who presented to the hospital's ED on 02/11/2013 at 1321 with complaints of headache. Review revealed the patient was diagnosed with headache prolonged with migraine features. The patient was discharged at 1835. Record review failed to reveal any available documentation a falls risk assessment was performed by nursing staff while the patient was in the ED.

Interview on 06/27/2013 at 1025 with the Senior Director of Clinical Services confirmed no documented evidence of a falls risk assessment was performed on Patient #16 while in the ED.

6. Closed ED record review on 06/26/2013 for Patient #19 revealed a 63 year old female who presented to the hospital's ED on 01/25/2013 at 1704 with complaints facial and finger burns. Review revealed the patient was diagnosed with multiple burns. The patient was transferred to another acute care hospital at 1900. Record review failed to reveal any available documentation a falls risk assessment was performed by nursing staff while the patient was in the ED.

Interview on 06/27/2013 at 1025 with the Senior Director of Clinical Services confirmed no documented evidence of a falls risk assessment was performed on Patient #19 while in the ED.

7. Closed ED record review on 06/26/2013 for Patient #20 revealed a 83 year old female who presented to the hospital's ED on 12/20/2012 at 1410 with complaints of fever. Review revealed the patient was diagnosed with fever, pyelonephritis, and urinary tract infection. The patient was admitted to an inpatient unit at 1838. Record review failed to reveal any available documentation a falls risk assessment was performed by nursing staff while the patient was in the ED.

Interview on 06/27/2013 at 1025 with the Senior Director of Clinical Services confirmed no documented evidence of a falls risk assessment was performed on Patient #20 while in the ED.

8. Closed ED record review on 06/26/2013 for Patient #22 revealed a 84 year old male who presented to the hospital's ED on 06/02/2012 at 1142 with complaints of injury to left knee secondary to a fall. Review revealed the patient was diagnosed with left knee joint instability and fall. The patient was discharged at 1537. Record review failed to reveal any available documentation a falls risk assessment was performed by nursing staff while the patient was in the ED.

Interview on 06/27/2013 at 1025 with the Senior Director of Clinical Services confirmed no documented evidence of a falls risk assessment was performed on Patient #22 while in the ED.

9. Closed ED record review on 06/26/2013 for Patient #25 revealed a 86 year old female who presented to the hospital's ED on 05/21/2010 at 1607 with complaints of fever. Review revealed the patient was diagnosed with fever and cough. The patient was discharged at 1744. Record review failed to reveal any available documentation a falls risk assessment was performed by nursing staff while the patient was in the ED.

Interview on 06/27/2013 at 1025 with the Senior Director of Clinical Services confirmed no documented evidence of a falls risk assessment was performed on Patient #25 while in the ED.

NC00084299