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Based on record review and interviews, the hospital failed to ensure the RN appropriately evaluated and assessed a patient's care needs, health status, and potential for injury in the emergency department for 1 (#1) of 5 (#1 - #5) patient records reviewed as evidenced by:

1) a patient assessed as a high fall risk was allowed to ambulate without the accompaniment of any emergency room staff; and

2) failure to assess the neurological status after a patient had a seizure and sustained an injury to the head/face while in the emergency department.
Findings:

1) a patient assessed as a high fall risk was allowed to ambulate without the accompaniment of any emergency staff

A review of the medical record for Patient #1 revealed she was a 28-year-old female who was brought to the ED via ambulance on 12/27/15 at 2:58 p.m. for active seizures.

A review of a policy entitled Fall Prevention Policy (Policy #: 3.16), presented as current, revealed, in part: ". . . 5. Definition of high fall risk: Patient demonstrates at least one of the fall risk elements listed below in Section 2 of the Procedure . . . 2. Patients should be assessed for the presence of the following high fall risk elements: . . . e. confused at times; f. fall history (last 3 months); h. lethargic/sedated. 3. Prevention of falls is the responsibility of all hospital personnel. The Fall Prevention Program consists of the following interventions: . . b. Customized interventions will be implemented for patients identified as being at risk of injury from a fall to include: iii. Patients will be provided with mobility assistance (i.e. walkers, walking/transfer belt).

A review of the ED nurses notes dated 12/27/15 by S4RN revealed Patient #1 was assessed to be a high risk for falls.

A review of the "Risk Management Report-Patient" dated 12/27/15 revealed, in part, Patient #1 was found on the floor outside of the bathroom in the emergency department actively seizing and bleeding from her mouth on 12/27/15 at 5:00 p.m. by an emergency room nurse. The report further stated the RN had observed, in passing, Patient #1 and a female friend outside the emergency department bathroom having casual conversation (no ED staff present with Patient #1). The RN documented she turned the corner to reach her destination, and she heard screams for help. When the RN returned to the location, the second female informed the RN that Patient #1 had fallen and hit her head on the floor.

In an interview on 02/23/16 at 10:33 a.m., S2ED Manager reviewed Patient #1's medical record and confirmed Patient #1 was allowed to ambulate to the bathroom unaccompanied by ED staff, and Patient #1 should not have been allowed to ambulate without ED staff present and should have been taken to the bathroom in a wheelchair by an ED staff member.

In an interview on 02/24/16 at 9:20 a.m., S4RN indicated he did not accompany Patient #1 to the bathroom, and he allowed Patient #1 to ambulate to the bathroom accompanied only by a female friend and no ED staff member. S4RN agreed, in hindsight, Patient #1 should not have been allowed to ambulate to the bathroom unaccompanied by an ED staff member.

In an interview on 02/24/16 at 11:00 a.m., S5RN indicated when patients are on fall precautions, especially high risk for falls for patients with seizures, changes in level of consciousness, etc. patients should not get up by themselves without a staff member present. She further indicated patients on high risk fall precautions should not be allowed to ambulate, but be transported in a wheelchair accompanied by a staff member. S5RN reviewed the medical record for Patient #1 and confirmed Patient #1 was allowed to ambulate to the bathroom in the ED without a staff member present, and Patient #1 should have been placed in a wheelchair and taken to the bathroom accompanied by an ED staff member.

2) failure to assess the neurological status after the patient sustained an injury to the head/face while in the emergency department.

A review of a policy entitled Seizure Precautions (NSG 4.25), presented as current, revealed, in part: "I. Purpose. The purpose of this policy is to provide nursing care and prevent injury to a patient who has a seizure. II. Policy: Any patient with a history of seizure disorder shall be placed on seizure precautions. Seizure precautions may be implemented as a nursing order. The physician will be notified of a patient placed on seizure precautions. V. Procedure: 8. a. After the seizure, monitor vital signs until stable. V. Documentation. 1. After a seizure the nurse is responsible for documenting the following: a. Seizure activity: time of onset, duration, description of seizure (motor involvement, tonic-clonic, type, etc.), time of intervals between seizure activity. b. Frequent vital signs, until stable. c. Level of consciousness. d. Any trauma/injury. f. Duration of the Post-Ictal phase."

A review of the Patient #1's medical record revealed the only assessment documented after Patient #1 had a seizure and fell and hit her head/face in the ED was a blood pressure assessment (120/90) taken by S4RN on 12/27/15 at 5:10 p.m. Further review revealed S4RN documented on 12/27/15 at 5:01 p.m., "post-ictal state at this time." There were no other vital signs, no description of the seizure activity, and there was no neurological assessment performed and documented by S4RN. Review of Patient #1's medical record revealed the first neurological assessment performed and documented (Glascow Coma Scale) after the patient had a seizure while in the ED and hit her head/face was on 12/27/15 at 6:11 p.m. by S6RN.

In an interview on 02/23/16 at 10:33 a.m., S2ED Manager reviewed Patient #1's medical record and confirmed the above findings and agreed that a full set of vital signs and a neurological assessment should have been performed and documented by S4RN immediately after the seizure and injury to Patient #1's head/face occurred. S4ED Manager also agreed "post-ictal state at this time" does not constitute a neurological assessment, and a neurological assessment should have included an assessment utilizing the Glascow Coma Scale.

In an interview on 2/24/16 at 11:00 a.m., S5RN reviewed the medical record for Patient #1 and, S5RN confirmed there was no documented neurological assessment performed on Patient #1 immediately after the patient had another seizure while in the ED and fell on the floor and hit her head/face resulting in a laceration to her lips, and there should have been neurological assessments performed and documented immediately after the seizure and head injury occurred.