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A. Based on document review and interview, it was determined for 3 of 4 (Pt #1, Pt # 2 and Pt # 4) Emergency Department (ED) patients reviewed for falls, the Hospital failed to assess/re-assess for fall risk and failed to provide fall interventions thus failed to ensure the provision of care in a safe setting for all patients. This has the potential to affect all ED patients, with an average daily census of 56 patients.

Findings include:

1. On 3/08/23 at approximately 11:00 AM the policy titled "Patient Fall Prevention (revised 7/1/22)" was reviewed. The policy stated, "... Process: I. Assessment: Assess at admission, every shift, change in level of care, after a fall, and day of discharge... A. Adult Patients.... 3. Emergency Department (ED) will screen patients using the ED Hester Davis Assessment and implement the ED intervention bundle for patients at risk for falls.... Documentation: Electronic Health Record.. Attachments: Attachment A - Note Writer."

2. On 03/07/23 at approximately 1:00 PM, Pt #1's record was reviewed. Pt #1 was admitted to the ED on 11/20/22 at 12:22 AM with chief complaints left knee, left leg and left wrist pain after a motor vehicle accident. Pt #1 had a fall risk assessment completed at 1:35 AM, fall interventions were in place with instructions given to pt and family. Pt #1's event report indicated Pt #1 fell at 3:30 AM. Pt #1's record lacked a fall risk re-assessment after the fall.

3. On 03/07/23 at approximately 2:00 PM, Pt #2's record was reviewed. Pt #2 was admitted to the ED on 11/05/22 at 11:27 AM with chief complaints of head laceration and seizure. Pt #2's record indicated Pt #2 fell at 5:15 PM. An event report stated, "(Pt family member) left and security was watching the patient from the nurses station. Pt leaned over railing as (Pt #2) had done before and when security got bedside pt had flipped out on floor hitting head on floor." Pt #2's record lacked documentation of an initial fall assessment and lacked documentation of fall prevention interventions.

4. On 03/07/23 at approximately 2:30 PM, Pt #4's record was reviewed. Pt #4 was admitted to the ED on 01/07/23 at 9:28 PM with a chief complaint of "fall - hit head." An event report indicated Pt #4 fell at 10:40 PM. Pt #4's record lacked documentation of an initial fall risk assessment, fall prevention interventions, and fall risk re-assessment after a fall.

5. On 03/07/23 during the record reviews, an interview was conducted with the Regulatory Specialist (E #1) and ED Director (E #6). E #1 and E #6 confirmed the above findings and verbally agreed the fall risk assessments/interventions were not completed and should have been.. E #6 stated, "I became the ED Director at the end of November. I have been working with the ED staff regarding other concerns. I have identified these concerns as well. I am just starting to work with the Fall Committee to improve this process."