HospitalInspections.org

Based on document review and interview, the facility could not validate (a) the development and implementation of their corrective action for a patient fall with injury event and (b) that training/education on the action plan was provided for all employees. This was identified for Patient #1.

Findings include:

Review of the facility "Confidential QA Review," dated August 2, 2019, identified:
The Emergency Departmental Quality Assurance Committee reviewed an event for a patient, (Patient #1) "who while in the ED stood up from stretcher and fell to the ground with a head strike and LOC (loss of consciousness); blood noted to be draining from right ear" The Head CT revealed and Acute right occipital fracture .....
- Departmental Determination: SOC (standard of care) Not Met - due to systems.
- Departmental Improvement Plan: Staff member involved will be counseled. Will review case at staff meetings and huddle.
- Due Date for Completion of Action Plan: September 30, 2019."

This report did not include " .... the formulation of action(s) taken to prevent recurrence, when appropriate." This action was included in the QA request for the review.


During interview with Staff C and Staff I, ED Directors, on 10/3/19 at 11:00 AM, the directors presented a one-page document titled "ED Huddle Message Of The Month, September 2019 - PLACING PATIENTS IN GOWNS". Staff stated this was a five (5) minute presentation. Everyone huddled when called so attendance is not taken. The document is also posted on the board for all to see who did not attend the presentation."

The document was a flow chart and the facility could verify the full training content.

When asked by the surveyor, the facility failed to identify the date of the meetings and the dates when it huddled with staff and did not have evidence of staff who attended, and that this presentation was given to all staff.


Review of the minutes for "Nursing Board (Quality Assurance and Performance Improvement)", Date: September 18th, 2019, identified the presentation of a fall with injury in the ED (Patient #1). Recommendations and Opportunities for improvement were discussed/documented.

There was no documented evidence that corrective action(s) plan was developed and that the recommendations were implemented.