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A. Based on document review and interview, it was determined that for 3 of 4 (Pt #1, Pt #2, and Pt #7) clinical records reviewed for patients seen in the Hospital's Emergency Department (ED), the Hospital failed to ensure the completion of a Fall Risk Assessment on patients on arrival to the ED.

Findings include:

1. The Hospital's policy titled, "Fall Risk Assessment/Fall Prevention Program" (revised 08/2017) was reviewed on 7/16/18 at approximately 2:00 PM and required, " ...Upon admission/or transfer, or change in condition, and after a fall has occurred, adult patients (includes inpatient and outpatient) should be assessed for risk for falls ..."

2. Pt #1's clinical record was reviewed on 7/16/18 at approximately 10:00 AM. Pt #1 was a 47 year old female, admitted to the ED on 3/7/18 with a diagnosis of agitation. Pt #1's clinical record lacked documentation of a Fall Risk Assessment.

3. On 7/17/18 at 9:35 AM, Pt. #7's medical record was reviewed. Pt. #7 was a 32 year old female, admitted to the Emergency Department (ED) on 1/23/18 for a urinary tract infection. Pt. #7's initial nursing assessment did not include a Fall Risk Assessment on arrival to the ED. Pt. #7's ED documentation, dated 1/23/18 at 3:44 PM, included, "Pt. [Pt. #7] stated that she fell off of [the] bed at about 3:15 PM ...no apparent injury noted ..."

4. The clinical record for Pt #2 was reviewed on 7/16/18 at approximately 10:15 AM. Pt #2 was a 56 year old male who presented to the Hospital's Emergency Department (ED) on 3/30/18 at 7:21 AM with complaints of lower back pain and swelling to spine. The nurse's (E #8) initial assessment of Pt #2 did not include a fall risk assessment. E #8's note, dated and timed 3/30/18 at 2:32 PM, included, "Pt found on ground in room. Stated that he fell asleep and fell out of bed and hit head. Fall was unwitnessed. Alert and acting at baseline." Pt #2's Fall Risk Assessment by E #8, completed on 3/30/18 at 2:37 PM (after Pt #2's fall), indicated a Morse Fall Risk Score of 50 (High Fall Risk), and the fall precautions indicated for Pt #2, based on this score, included the call light within reach and side rails up for support. These precautions were not put into place until after Pt #2's fall.

5. During an interview with the Director of Risk Management (E #6), on 7/17/18 at approximately 10:45 AM, E #6 stated that a fall risk assessment should be completed on every patient on arrival to the ED.


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B. Based on document review, observation and interview it was determined that for 1 of 4 patients (Pt. #5) reviewed for falls, the Hospital failed to ensure that fall safety precautions were implemented.

Findings Include:

1. On 7/16/18 the Hospital's policy titled, "Fall Risk assessment/Fall Prevention Program" (revised 8/17) was reviewed. The policy required, "2. Interventions for patients with Morse scale equal to or higher than 45 ...patient may need shoes rather than slippers for no-skid footwear and support ...Once the patients identified as a high risk, a visible fall risk identifier will be placed on the patient."

2. On 7/16/18, Pt. #5's medical record was reviewed. Pt. #5 is a 90 year old female admitted for hypotension on 7/10/18. Pt. #5's Fall Risk Assessment, completed on 7/16/18 at 1:16 AM, indicated a Morse (fall risk model) Fall Risk score of 50 (High Fall Risk).

3. On 7/16/18 at approximately 11:20 AM, an observational tour was conducted of the telemetry/stroke unit. A safety risk sign was observed on the door of Pt #5's room. Pt. #5 was observed resting in bed without a safety risk armband or no-skid socks in place.

4. On 7/16/18 at approximately 11:25 AM, an interview was conducted with the telemetry/stroke unit Charge Nurse (E #3). E #3 stated that Pt. #5 should have the yellow safety arm band and no-skid socks in place, due to fall risk. E #3 stated that yellow arm bands, yellow no-skid socks and bed alarms are interventions for the fall risk protocol.