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Based on document review and interview, the nurse failed to ensure a patient safety event was reported/entered in the Event Reporting System (ERS) in one (1) instance. (Patient # 10)

Findings include:

1. The hospital policy titled, "Event Reporting Policy", version 2, reference CHS PSO, indicated the staff member involved in the patient safety event should report the event in ERS as soon as possible or by the end of the work shift. This policy was last revised on 04/21/2020.

2. The Event Log dated 11/01/2022 through 03/09/2023 lacked a documented event for patient # 10.

3. Patient # 10's medical record (MR) indicated the patient arrived to the Emergency Department (ED) on 12/28/2022 after falling at home. On 12/29/2022, while still in the ED, the patient fell and sustained injuries.

4. In interview on 03/09/2023 at approximately 1:54 pm with administrative staff member A # 1 (Assistant Chief Nursing Officer), confirmed the event was not entered in the ERS system and the nurse should have entered it.

Based on document review and interview, the nurse failed to follow policies and procedures related to completing a post fall huddle and initiating neurological checks after a patient fall in one (1) instance. (Patient # 10)

Findings include:

1. The hospital policy titled, "Fall Prevention Policy", no policy number, indicated to utilize the Post Fall Event Checklist related to caring for a patient's immediate clinical needs post fall. Conduct a Post-Fall Huddle as soon as possible after the fall. This policy was last revised on 11/17/2020.

2. Review of the Post-Fall Critical Event Checklist, indicated for all patients where head injury has occurred or cannot be excluded (such as unwitnessed fall) perform neurological assessment, record vital signs and observation for at least 24 hours post fall. The Neurological Assessment indicated to assess the patients general appearance-level of consciousness, behavior affect, Glasgow Coma Scale, awareness, vital signs every hour for 2 hours, then every 2 hours twice, then every 4 hours for 24 hours, and inspect the pupil response, coordination/motor response, muscle strength and sensory response.

3. Patient # 10's medical record (MR) indicated on 12/28/2022 the patient was admitted after having a fall at home. Patient Care Note dated 12/29/2022 at 8:00 am by S # 2 (Registered Nurse-RN), indicated the nurse placed patient # 10 on the bedside commode and left the room. Upon returning to the patient's room the patient was found on the floor with a left black eye and a small scrape on the left side of the patient's head. The medical record lacked neurological assessment completion per policy.

4. Review of documents indicated no post fall huddle was completed/performed for patient #10.

5. In interview on 03/09/2023 at approximately 4:25 pm with administrative staff member A # 2 (Director of Quality), confirmed the nurse should have treated the fall as a critical event and used the Post-Fall Critical Event Checklist.

6. In interview on 03/09/2023 at approximately 4:30 pm with administrative staff member A # 1 (Assistant Chief Nursing Officer), confirmed the nurse failed to complete/perform a Post-Fall Huddle.

7. In interview on 03/09/2023 at approximately 4:45 pm with administrative staff member A # 3 (Chief Nursing Officer), confirmed according to the Post-Fall Critical Event Checklist the nurse should have completed the neurological assessment.