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Based on record review and interview for one (Patient #4) of ten medical records reviewed. It was determined the hospital failed to have a fall risk assessment performed at the time of triage or at the time of the secondary assessment in the Emergency Department (ED) to ensure a safe environment of care.

Findings include:

The hospital policy and procedure titled, Patient Fall Prevention and Management, dated 4/7/2020, indicated that in the Emergency Department (ED) a nurse will complete a Johns Hopkins fall risk assessment for every adult patient and when appropriate a Humpty Dumpty for pediatric patients. Fall prevention interventions will be individualized and implement into the patients care. The policy did not indicate when in the ER a patient will be assessed for a fall risk.

Patient (Pt) #4's medical record, dated 5/3/21, indicated Pt #4 arrived at 7:30 A.M.

During an interview with the Nursing Infomatics Manager at 11:45 A.M. on 5/4/21, and review of Pt #4's ED record with the Nursing Informatics Manager indicated no evidence that the fall risk assessment had been performed. The Nursing Infomatics Manager said a fall risk assessment will be performed at triage or during the secondary assessment.

Continued review of Pt #4's ED record with the Manager of Nursing Infomatics indicated Pt #4's fall risk assessment was performed on 5/4/21 at 12:09 P.M., 28 and ½ hours after Pt #4 arrived to the ED, after the Surveyor identified the fall risk assessment had not been performed at arrival to the ED or at the time of the next nursing assessment in the ED.

Based on record review for one (Patient #8) of ten medical records reviewed it was determine the Hospital failed to have a licensed practitioner or a physician ordered a restraint prior to the application of the restraint being applied to Patient #8.

Findings include:

The Hospital's policy and procedure titled, Restraint and Seclusion for Non-Behavioral Health Units, dated 3/31/20, indicated the patient's treating physician and or his/her delegated licensed independent practitioner orders the appropriate type of restraint prior to the application.
Patient #8's medical record, dated 12/23/20, indicated that 8:00 A.M. the nursing staff applied soft wrist restraints to Pt #8's right and left wrist because he/she was pulling at intravenous line and tubes.

Continued review of Pt 8's medical record, dated 12/23/20, indicated the physician's order was written 11 and ½ hours after the soft wrist restraints were applied.