HospitalInspections.org

Based on medical record review, policy review and interview, the facility failed to conduct a fall risk assessment in accordance with its procedure for eight (Patient #1, #2, #3, #4, #5, #6, #7 and #8) of nine medical records reviewed for fall risk assessments.

Findings include:

The facility's Triage Process (Revision 1, Approved 02/28/20) stated:
Emergency Department (ED) triage is to prioritize incoming patients and to identify those patients who cannot wait to be seen. Triage is a process and every attempt is made to maintain privacy.

PROCEDURE:
1. The Registered Nurse (RN) evaluates and categorizes each patient upon arrival to the ED into immediate, emergent, urgent, less-urgent, and non-urgent categories.
2. The initial evaluation includes:
a. Confirmation of patient's name and date of birth.
c. Chief Complaint: provide a description and onset of symptoms. Use subjective and objective data.
d. Core Measures: Patients with stroke symptoms need patient's last known well (LKW), date and time.
e. Vital Signs on all patients:
1.) First BP (blood pressure) must be done manually.
2.) BP taken on all adult patients. Infant and children will have blood pressure monitoring based on injury and severity.
3.) Temperature must be taken rectal for patients less than one year.
f. Height and accurate weight.
g. Complete Travel and Screening Questions as appropriate: include mandatory screenings such as:
Columbia Suicide Severity Rating Scale (C-SSRS), Morse Fall Screening (patients 18 yrs. old and greater), and Pediatric Falls Assessment Screening (less than 18 yrs. old). (See Fall Prevention, Pediatric Guideline; also refer to Lippincott procedures, Fall Prevention: Pediatric.)

1. Patient #1, 17-years-old, was treated in the emergency department on 09/28/21. The medical record did not contain a fall risk assessment.

The findings were shared with Staff R on 11/17/21 at 9:30 AM and confirmed.

2. Patient #4, 14-years-old, was treated in the emergency department on 11/15/21. The medical record did not contain a fall risk assessment.

The findings were shared with Staff R on 11/17/21 at 9:30 AM and confirmed.

3. Patients #2, #3, #6, #7, and #8 were treated in the emergency department on 11/15/21. The medical records did not contain a fall risk assessment.

The findings were shared with Staff R on 11/17/21 at 1:48 PM and confirmed.

4. Patient #5 was treated in the emergency department on 09/05/21. The medical record did not contain a fall risk assessment.

The findings were shared with Staff R on 11/17/21 at 1:48 PM and confirmed.