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Based on observation, interview and record review, the hospital failed to ensure that a Registered Nurse (RN) performed an assessment after a fall in the Emergency Department (ED), for 1 of 30 sampled patients (2) in accordance with the hospital's policy. There was no documented evidence that a post-fall assessment had been performed on Patient 2.

Failure to ensure that a post-fall assessment had been documented in the medical record, made it difficult to determine whether or not the patient was assessed for injuries and treated after sustaining a fall in the ED.

Findings:

On 12/5/16 beginning at 10:36 A.M., a tour of the hospital's Emergency Department was conducted with the Assistant Chief Nursing Officer (ACNO) and the Chief Strategy Officer. General observations were conducted.

Patient 2 presented to the ED on 9/9/16 at 10:53 A.M. after sustaining a fall at home, per the Nurse's Notes, dated 9/9/16. Per the Nurse's Notes, Patient 2 was diagnosed with arthritis (painful inflammation and stiffness of the joints). Patient 2 was identified a fall risk. There was no documented evidence to demonstrate that Patient 2 had a fall in the ED. In addition, a post-fall assessment was not found in the medical record.

A joint record review and interview with Registered Nurse (RN 1) was conducted on 12/6/16 at 2:43 P.M. RN 1 stated that she was Patient 2's primary nurse on 9/9/16 from 7:00 A.M. to 7:30 P.M. RN 1 stated that she was informed by another nurse that Patient 2 had an unwitnessed fall. Per RN 1, vital signs were taken and a head-to-toe assessment (post-fall) was completed however, the documentation was not found in the medical record. RN 1 also acknowledged that Patient 2's medical record did not contain any documentation of the patient's fall in the ED. The lack of documentation in Patient 2's medical record was not in accordance with the hospital's policy.

The hospital policy titled "Assessment/Reassessment and Vital Signs; Temperature, Pulse, Respiration, Blood Pressure", last review date of 6/5/16, was reviewed. The policy indicated that "100% of patients in the ED will have a complete (Primary-Secondary) head to toe assessment of body systems performed and documented by a Registered Nurse. Head to toe reassessment of body systems, when clinically indicated. Targets reassessment after nursing interventions with findings documented and if required report to the MD (Medical Doctor - physician)."

According to a hospital document titled "Postfall Assessment, Clinical Review" (undated), under important communication, the document indicated that "In the medical record, document the incident [fall], outcome, and initial and ongoing observations, and update fall risk assessment and care plan. Notify the treating medical provider at the time of the incident...."

An interview with Physician 1 was conducted on 12/6/16 beginning at 1:15 P.M. Physician 1 stated that he recalled being informed by someone in the ED that Patient 2 had gotten out of bed and fell on his knee. At 3:26 P.M., Physician 1 stated that "it's common practice to document the assessment after a fall". Physician 1 acknowledged that there was no physician documentation found in the medical record of an assessment after Patient 2's fall in the ED.

An interview with the Senior Director of Quality (SDQ) was conducted on 12/6/16 at 3:21 P.M. The SDQ agreed that there was no documented evidence of a head to toe assessment (reassessment) after Patient 2 sustained a fall in the ED. The SDQ stated that the hospital's policy and practice were not implemented when there was no documentation in the medical record reflecting a fall and the completion of assessments after the fall.

Based on interview and record review, the hospital failed to ensure that the medical record contained the following: the patient's fall in the Emergency Department (ED), a head-to-toe assessment after the fall, physician notification, physician post-fall exam, and family or responsible person notification, for 1 of 30 sampled patients (2) after sustaining a fall in the ED.

Failure to document a patient's fall in the ED, a head-to-toe assessment, physician notification, physician post-fall exam, and family or responsible person notification, made it difficult to determine whether or not assessments and interventions were performed and implemented, in an effort to immediately identify injuries and provide necessary treatment.

Findings:

Patient 2 presented to the ED on 9/9/16 at 10:53 A.M. after sustaining a fall at home, per the Nurse's Notes, dated 9/9/16. Per the Nurse's Notes, Patient 2 was diagnosed with arthritis (painful inflammation and stiffness of the joints). Patient 2 was identified a fall risk. There was no documented evidence found in the medical record, to demonstrate that Patient 2 had a fall in the ED, a post-fall assessment had been performed by nurse and physician, physician was notified and family or responsible person was informed.

A joint record review and interview with Registered Nurse (RN 1) was conducted on 12/6/16 at 2:43 P.M. RN 1 stated that she was Patient 2's primary nurse on 9/9/16 from 7:00 A.M. to 7:30 P.M. RN 1 stated that she was informed by another nurse that Patient 2 had an unwitnessed fall. Per RN 1, vital signs were taken and a head-to-toe assessment (post-fall) was completed however, the documentation was not found in the medical record. RN 1 also acknowledged that Patient 2's medical record did not contain any documentation of the patient's fall in the ED, physician and family or responsible person notification. The lack of documentation in Patient 2's medical record was not in accordance with the hospital's policy.

The hospital policy titled "Assessment/Reassessment and Vital Signs; Temperature, Pulse, Respiration, Blood Pressure", last review date of 6/5/16, was reviewed. The policy indicated that "100% of patients in the ED will have a complete (Primary-Secondary) head to toe assessment of body systems performed and documented by a Registered Nurse. Head to toe reassessment of body systems, when clinically indicated. Targets reassessment after nursing interventions with findings documented and if required report to the MD (Medical Doctor - physician)."

According to a hospital document titled "Postfall Assessment, Clinical Review" (undated), under important communication, the document indicated that "In the medical record, document the incident [fall], outcome, and initial and ongoing observations, and update fall risk assessment and care plan. Notify the treating medical provider at the time of the incident...."

An interview with Physician 1 was conducted on 12/6/16 beginning at 1:15 P.M. Physician 1 stated that he recalled being informed by someone in the ED that Patient 2 had gotten out of bed and fell on his knee. At 3:26 P.M., Physician 1 stated that "it's common practice to document the assessment after a fall". Physician 1 acknowledged that there was no physician documentation found in the medical record of an assessment after Patient 2's fall in the ED.

An interview with the Senior Director of Quality (SDQ) was conducted on 12/6/16 at 3:21 P.M. The SDQ agreed that there was no documented evidence of Patient 2's fall in the ED, physician notification, a post-fall assessment performed by the nurse and physician, and that the family or responsible person was notified. The SDQ acknowledged that the lack of documentation was not in accordance with the hospital's policy.