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Based on observation, interview and record review, the facility failed to provide care in a safe setting for 1 of 31 sampled patients (Patient 1) when he was intoxicated and agitated. As a result, Patient 1 got out of bed unsupervised, dressed himself in wet clothes and then fell in the Emergency Department (ED). Patient 1 sustained an intracranial hemorrhage and required transfer to a trauma center and admission to ICU. The patient later was discharged from rehab with cognitive deficits and no longer able to care for himself.

Findings:

Patient 1 was admitted to the facility on 5/27/13 at 1:34 P.M. according to the Emergency Medical Services (EMS) report. According to the same report, prior to his arrival in the Emergency Department (ED), Patient 1 was seen standing chest high in a nearby lake looking for his dog and refusing to get out of the lake. The EMS report noted the patient smelled of "heavy ETOH" (alcohol).

Upon arrival to the ED, Patient 1 had a blood alcohol concentration of .434, five times the legal limit. Patient 1 was placed in a room in the back of the ED (room 15) with 3 other patients. When interviewed on 7/12/13 at 3:10 P.M., the Charge Nurse (CN) stated the ED was very busy and in order to accommodate EMS staff, she moved Patient 1 to the back. Retrospectively, the CN stated the better placement would have been up front where he was visible to all staff.

Registered Nurse (RN) 1 was interviewed 7/12/13 at 3 P.M. According to RN 1, she was covering for RN 2, who was on break. RN 1 received Patient 1 into the back room (15) and noted he was "Very agitated and fighting with staff. Pt. (patient) advised several times to remain in bed and security at bedside." RN 1 stated the patient was fighting, didn't want to stay and would not even sit down. She said she observed Patient 1 attempting to get out of bed and had seen him crawl out the bottom of the bed.

During an interview on 7/16/13 at 7:05 A.M., the Security Officer stated he was called to the ED to assist with Patient 1. The officer stated Patient 1 was disoriented and crying. He stated Patient 1 had been disrobed due to wet clothing, and was "non cooperative, extremely emotional." According to the Security Officer, he observed Patient 1 attempting to get out of bed several times. The officer stated that when he left the ED, Patient 1 was sitting on the edge of the bed. He recalled this all happened between the hours of 2 and 2:45 P.M. on 5/27/13.

RN 2 was interviewed on 8/2/13 at 2 P.M. According to RN 2, she was on break and when she returned from lunch, the CN had opened up the back of the ED with 4 new patients, one of which was Patient 1. RN 2 stated she saw RN 1, the CN and security handling Patient 1 as he was drunk and uncooperative. RN 2 stated she thought she would try to catch up on the other 3 patients while Patient 1 was being attended to by other staff. According to RN 2, while she was busy with other tasks, the CN allowed security to leave, without telling RN 2. RN 2 stated she heard Patient 1 rumbling around the room and before she could get to him he had fallen on the floor.

The ED physician (ED 1) on duty on 5/27/13 was interviewed on 8/2/13 at 2:10 P.M. According to ED 1, he walked by the room and saw at the bottom of a closed curtain, Patient 1's feet in a puddle with his hands attempting to pull up his pants. According to ED 1, just as it occurred to him this didn't look right, he heard a thump and observed Patient 1 had fallen straight back onto his head.

A Computed Tomography (CT scan- a 3 dimensional X ray) scan of the brain was ordered on 5/27/13 at 2:32 P.M. and the results indicated "Parenchymal, subdural, and subarachnoid bleeding" (bleeding inside the brain). ED 1 intubated Patient 1 and transferred him to the local trauma center for treatment of a traumatic brain injury.
The Trauma Surgeon who cared for Patient 1 was interviewed by telephone on 8/27/13 at 12 P.M. According to the surgeon, Patient 1 suffered an intracranial bleed with persistent neurological impairment. He stated the second CT of the brain upon arrival to the trauma center was "Significantly more prominent than the initial CT." The results of the CT of the brain upon arrival to the trauma center were as follows: "Markedly increased size of left sided temporal lobe and bifrontal hemorrhagic contusions. Left sided acute subdural or epidural hematoma grossly unchanged in size compared with prior study ..." The Trauma Surgeon stated, when Patient 1 was discharged he was "Not normal." "It's hard to know how much recovery he'll make."

Patient 1 spent the next 3 days (5/27-5/30/13) in the ICU and was transferred to the Trauma Intermediate care unit. On 5/30-6/8/13 he was transferred to the Acute Rehabilitative Center (ARU). Patient 1 underwent physical therapy, occupational therapy and speech therapy. On 6/21/13, Patient 1 was discharged into the care of his brother.
The Rehab physician (MD 1), following Patient 1 during his rehabilitative phase of recovery, was interviewed on 8/28/13 at 2 P.M., by telephone. MD 1 stated Patient 1, "Will probably always have word problems. For example he may be speaking and when he wants to say orange, he'll say apple, even though he may realize he meant to say orange."

The discharge summary by MD 1 was reviewed with MD 1 on 8/28/13 at 3 P.M. The patient was evaluated in 18 different categories and rated on a Functional Independent Measures Scale from 1-7, with the number 1 indicating totally dependent and 7 independent. Patient 1's comprehension was rated "5", expression "3", social interaction "5" and problem solving and memory improved to a "5".

RN 2 was re-interviewed on 10/22/43 at 11:30 A.M. regarding the fall incident. According to RN 2, when she returned from lunch break, she was assigned 4 new patients, including Patient 1. RN 2 saw that staff and security were with Patient 1, so she went to check on the other 3 patients. According to RN 2, while she was busy with other patients, the CN allowed security to leave without telling her. RN 2 was at the desk when she heard Patient 1 fall. The patient was awake and talking when found, but became more agitated so the MD decided to intubate the patient.

The failure of the nursing staff in the ED to plan for and provide a safe environment for Patient 1 when he arrived intoxicated resulted in the serious disability of Patient 1, which continued up to and after discharge from the facility.