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Based on policy review, medical record review, and staff interview, it was determined the hospital failed to ensure care was provided in a safe setting for 1 of 3 patients (Patient #1) whose records were reviewed and included a fall Additionally, this impacted 1 of 1 patient (Patient #2) whose care was observed in the ED. This had the potential to affect all patients receiving care in the ED. Findings include:

1. The facility failed to implement, and document fall interventions. Examples include

A facility policy titled, "Patient Fall Prevention," dated 10/13/22 included, "Emergency Department Only: Universal fall interventions apply." The policy included, under the section Universal Fall Precautions: 11 interventions that should be implemented to prevent patient falls, including:

- "Assuring availability of non-skid foot wear ..." The policy also included the use of a bed alarm, video monitoring, 1:1 patient safety attendant, and utilizing a "Yellow falling star" to indicate to other staff the patient is a fall risk. This policy was not followed. An example included:

a. Patient #1 was a 64 year old male who presented to the ED on 10/28/2022 with a diagnosis of seizure activity. His record included a fall in the ED

Patient #1's record stated he arrived in the ED at 1:55 AM. There was no order for fall precautions until 5:51 AM. The first documented fall risk assessment was done at 8:24 AM, 6 hours and 29 minutes after he arrived to the ED. The fall risk assessment included, "Last Known Fall: During the current hospitalization." Patient #1's record included a documented fall at 8:30 AM. There was no documentation in Patient #1's record that universal fall precautions and interventions were implemented prior to his fall at 8:24 AM.

The RN Manager was interviewed on 11/09/22 beginning at 2:00 PM, and Patient #1's record was reviewed in her presence. The RN Manager confirmed there was no documentation universal fall precautions and interventions were initiated prior to Patient #1's fall at 8:24 AM.

The ED Charge RN was interviewed on 11/08/22 beginning a 10:33 AM. She stated a fall risk assessment should be done on all ED patients upon triage.

The facility failed to document Patient #1's fall risk assessment and implement fall precautions.

b. On 11/08/22 beginning at 10:33 AM, observations were conducted of the ED with the Charge RN. The Charge nurse was asked about the "Yellow Falling Star" as mentioned in the facility policy. She stated the stars cannot be utilized in the ED due to the fact the magnets do not stick onto the aluminum door frames. She stated they utilize a yellow "fall light" to indicate the patient is at risk for falling. When asked if any patients currently in the ED were considered a fall risk, the Charge RN confirmed Patient #2 was considered a high fall risk and should be on fall precautions. The Charge RN, and surveyors went to Patient #2's room. Patient #2's yellow light was not on to indicate fall risk to other ED staff. The Charge RN confirmed Patient #2 should have had a yellow light turned on outside her room to signal fall risk.

The Facility failed to implement fall precautions for Patient #2.

2. The facility failed to maintain seizure protocol.

A facility policy titled, "Seizure Precautions," dated 7/9/18 included, "The registered nurse will assess and maintain the safety of patients who are having a seizure, or who are at risk of having a seizure." The policy stated after seizure activity, vital signs and neurological status should be monitored every 15 minutes until the patient is stable and returns to baseline. This policy was not followed. An example included:

Patient #1 was a 64 year old male who presented to the ED on 10/28/2022 with a diagnosis of seizure activity. His record included a fall in the emergency room and additional seizure activity.

Patient#'1's medical record included documentation of a seizure at 3:00 AM. The first documented vitals were at 5:01 AM, 2 hours and 1 minute after the seizure activity.

The RN Manager was interviewed on 11/9/22 beginning at 2:00 PM, and Patient #1's record was reviewed in her presence. The RN Manager confirmed vitals were not taken on Patient #1 until 5:01 AM, two hours and 1 minute after his documented seizure activity.

The facility failed to follow policy related to seizure precautions and monitoring.