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Based on medical record (MR) review, interview and document review, the hospital investigated an adverse event, a patient fall with injury in the emergency department (ED). However, the hospital did not ensure this event was fully investigated, analyzed and monitored to prevent recurrence. This could put other patients safety at risk.

Findings include:

-- Per MR review, on 9/25/2020, Patient #1, an 85-year-old male with a medical history of heart failure and dementia, presented to the ED with increasing mental status changes. Emergency Department nursing staff documented that the patient's family reported the patient was increasingly agitated since prior evening and that evening became sleepy. The patient also had a lower leg wound/possible cellulitis.

At 9:38 pm staff assessed the patient and documented the patient's fall risk using the Hendrich II Fall Risk Scale: (a scale of 0 - 16, patients with a score of 5 or greater are at high risk for falling)
Fall Risk Assess/Prevention
Impaired Judgment Fall Risk Hendrich II : (4) Yes
Depression Fall Risk Hendrich II : (0) No
Incontinence Fall Risk Hendrich II : (1) Yes
Dizziness Vertigo Fall Risk Hendrich II : (0) No
Male Fall Risk Hendrich II : (1) Yes
Antiepileptics Fall Risk Hendrich II : (0) No
Benzodiazepines Fall Risk Hendrich II : (0) No
Rising from Chair : (0) Unable to assess
Hendrich II Fall Risk Score : 6
Patient considered to be at risk for fall? : Yes
Standard Safety: Bed brakes locked, Bed in low position, Call device within reach, Gait belt, Low bed, Non-slip
footwear, Patient/auth rep education, Room free of obstructions, Supportive device, Upper/Half-length siderails up, Wheels locked
High Risk Fall Prevention Measures: Companionship, Pt/authorized representative instructed to verbally call RN for
assistance
Loc Modified Hendrich II Score : 11

On 9/26/2020 at 12:01 am, an ED Physician Assistant (PA) documented that the patient's confusion was likely due to worsening dementia and assistance in placement (in long term care) may be needed as patient lived at home with his spouse who was unable to care for him. Decision was made to admit the patient.

At 1:10 am, family had left the bedside.

At 3:00 am, staff reassessed the patient and documented the patient was alert and oriented, forgetful at times and did not remember to use his call bell and that the patient was strong 2 assist from bed and was "able to get self to end of bed."

At 6:41 am, staff documented that the patient reoriented easily and continued to be a strong 2 assist to bedside commode and the patient was able to make needs known.

At 7:40 am, staff documented that the patient was resting on stretcher with eyes closed, respirations easy and non-labored.

At 9:17 am, an Attending ED Physician documented being called emergently to the patient's bedside for a fall, that the patient was boarding in the ED awaiting an open bed and was admitted for lethargy. The patient was found lying on the floor with a deformity of his right femur.

-- Per interview of Staff A (provided care to Patient #1) on 5/17/21 at 7:30 am, he/she recalled the patient. Patient was in room #18 in ED. Recalled the patient was admitted with confusion and had a wound on his leg. Documented that the patient was forgetful, was a "strong 2 assist," (which meant that it took a lot of effort for 2 staff to get him up out of stretcher) and was able to get to the end of bed. Recalled the family left at 1:00 am. He/she checked on patient frequently and that the patient reoriented easily. Recalled performing Fall Risk assessment and that patient was at risk for fall. Fall prevention interventions were put in to place. Recalled that he/she had found Patient #1 trying to get off the stretcher and was starting to "scooch" to the end of the bed. He/she told patient they would help him get back in the bed and assisted him. There was not a bed alarm on the stretcher. Recalled that at the time of the patient's ED presentation, it was difficult to get a bed alarm in the ED and they were not stocked on ED cart.

-- Per interview of Staff B, Director of the ED on 6/15/2021 at 9:15 am, he/she recalled Patient #1 was being held in the ED awaiting an inpatient bed. There were not any bed alarms available in the ED at that time. If someone was identified as a high risk to fall, they would sometimes request a sitter. He/she indicated bed alarms were not part of the process in the ED.

-- Per review of the hospital root cause analysis (RCA), investigation into the fall was initiated on 9/28/2020. Overall the completed RCA determined the standard of care (SOC) was met. The review indicated the Fall Policy and Procedure (P&P) was followed and nursing care met expected practice.

However, the RCA lacked completeness. For example:

1) The RCA review indicated the patient had not made any attempt to get out of bed. Per MR review on 9/26/2020 at 3:00 am, Staff A documented he/she reassessed the patient and the patient was alert and oriented, forgetful at times and did not remember to use his call bell and that the patient was strong 2 assist from bed and was "able to get self to end of bed."

2) The RCA indicated participants included involved nursing staff. No interview notes were available for review. Per interview of Staff A on 5/17/21 at 7:30 am, he/she shared that Patient #1 was found trying to get off stretcher and was starting to "scooch" to the end of the bed. This was not documented in the investigation.

3) The timeline of the RCA did not include nursing documentation that indicated on 9/25/20 at 9:38 pm, Staff A documented Additional High-Risk fall prevention measures: "companionship, patient/authorized representative instructed to verbally call RN." LOC modified Hendrich II score: 11. Also on 9/26/20 at 1:10 am, documentation revealed the patients family member had left the bedside. The lack of this information in the timeline prevented discussion of and possible opportunity for improvement..

4) The RCA indicated one of the fall prevention interventions documented was call bell in reach. Nursing documentation revealed on 9/26/20 at 3:00 am, patient forgetful at times and did not remember to use call bell.

This RCA indicated that nursing met standard of care. The lack of a complete RCA may not have led to an accurate determination. Without a complete RCA and an acute outcome determination, effective changes and monitoring cannot occur.

Based on document review, medical record (MR) review and interview, in 5 of 11 MRs reviewed, the emergency department (ED) nursing staff did not document an accurate and complete fall assessment and/or all of the preventative measures that were implemented on individuals at risk for fall. Additionally, the policy and procedure (P&P) lacked instruction to ED staff on the appropriate preventative measures to implement in the ED. This could cause patients to be at risk for fall and/or patient injury.

Findings include:

-- Review of the hospital's P&P titled "Fall Prevention," last revised 5/2021, indicated upon admission to the ED the registered nurse (RN) should consider input from other members of the nursing team, assess all patients for risk to fall using the Morse Fall Scale. The P&P describes the interventions that should be implemented on the inpatient units e.g., yellow fall bracelet, post a red fall sign outside room, apply "high alert" red skid resistant socks, etc., but does not indicate these interventions should be used in the ED.

-- Review of Patient #2's MR (96-year-old male) indicated he presented to the ED via emergency medical services (EMS) on 6/14/2021 at 7:45 pm with a chief complaint of shortness of breath. The fall risk assessment documented by Staff G, Registered Nurse (RN) indicated, Patient #2 was weak. The assessment for risk for injuries for patients over 80-years-old was not completed, therefore he was not identified as a fall risk. (Fall prevention measures were documented, e.g., bed brakes locked, bed in low position, call device within reach, night light, non-slip footwear,etc.)

-- Review of Patient #3's MR (70-year-old female) indicated, she presented to the ED via EMS on 5/15/2021 at 4:11 pm with a chief complaint of a syncopal episode lasting approximately 1 minute. The fall risk assessment score documented by Staff H (RN) was 0, no risk to fall. (Fall prevention measures were documented.)

-- The same lack of accurate fall assessment and/or all safety precautions implemented was noted in Patients #4, # and #6's MRs.

-- During interview of Staff I (RN ED) on 6/15/2021 at 12:30 pm, he/she acknowledged the above findings. Staff I indicated all patients should receive a complete fall risk assessment. Any patient that comes to the ED after a fall or syncopal episode should be documented as a fall risk. Patients 80-years-old and above also need the additional assessment for risk for injury completed. Fall risk patients should have red slipper socks, fall bracelet, side rails x 2 and a bed alarm if they are high risk to fall.