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Based on interview and record review, the facility failed to ensure the representative of one patient (Patient A) was informed of the patient's health status in a timely manner, which resulted in a delay in advocating for the patient.

Findings:

During an interview with Family Member (FM) 1 on 10/28/10 at 10:46 AM, she stated Patient A fell at the facility on 9/12/10 at 7:00 PM, but the facility didn't call her until 9/13/10 at 2:00 AM. The fall led to Patient A's death. On 5/31/11 at 9:25 AM, FM 1 added, "The hardest part was the delay in notifying me and the horrific way (Patient A) died."

The clinical record for Patient A indicated he fell on 9/12/10 at 7:05 PM. The patient sustained a laceration near the right eyebrow and was bleeding from the mouth. At 8:50 PM the patient was bleeding from the nose and mouth. He was moved to the trauma room. At 9:15 PM the patient was repeatedly suctioned due to blood in the mouth. He was determined to be a 9 on the Glasgow coma scale (15 equals no impairment, 7 equals coma. The patient arrived at the facility with a GCS of 12). At 11:05 PM his consciousness remained altered with incomprehensible words and continued bleeding from the mouth. He required sutures to the head. At midnight the patient required oxygen due to decreased oxygen saturation (92-93%). At 12:05 AM on 9/13/10 an order for a CT scan (A computerized axial tomography scan is an x-ray procedure that combines many images to generate cross-sectional views and three-dimensional images of the internal organs and structures of the body) was obtained which revealed a subdural (beneath the outer membrane covering the brain) bleed. At 2:00 AM, FM 1 was called and agreed to intubation. Patient A ultimately passed away on 9/13/10 at 10:46 PM.

During an interview with Registered Nurse (RN) 1 (who cared for Patient A up until the time of the fall) on 3/16/11 at 2:38 PM, he stated that after the fall the patient's "eyes were open but he was in a daze, couldn't verbalize or move his extremities, like in shock, a change in condition."

On 1/20/11 at 11:55 AM Quality Staff (QS) 1 was asked for documentation of timely notification of Patient A's representative of his fall and injuries. Again on 3/23/11 at 10:45 AM QS 1 and the Quality Manager (QM) were asked to provide information regarding timely notification of Patient A's representative, but this information was not provided. On 4/26/11 at 10:30 AM QS 1 was asked for a facility policy regarding the time frame allowed to notify a patient's representative of changes in condition, but no such policy was provided.

Based on interview and record review the facility failed to provide adequate fall prevention procedures in the Emergency Department (ED) for one patient (Patient A), which had the potential to result in patient falls.

Findings:

The facility policy titled "Fall Risk Assessment and Prevention" dated November 2008 indicates in part, "...a Fall Risk Assessment is completed and preventative measures are implemented based on the level for risk."

On 9/13/10 at 6:39 PM the facility reported Patient A had a fall on 9/12/10 at 7:05 PM while in the ED. The patient subsequently passed away on 9/13/10 at 10:46 PM from injuries sustained during the fall. At that time the patient had been in the ED for 57.5 hours. The only fall risk assessment found in the record was dated 9/13/10 at 7:00 AM.

On 1/20/11 at 11:55 AM Quality Staff (QS) 1 was asked for evidence of a timely fall risk assessment and/or a fall prevention care plan for Patient A. On 3/16/11 at 1:57 PM QS 1 stated "For some reason they didn't have a treatment plan on (Patient A), a nursing care plan for interventions. After a certain period of time they are supposed to initiate a nursing care plan."

During an interview with Registered Nurse (RN) 3 on 2/17/11 at 1:47 PM, she stated Patient A "definitely was a high fall risk because he wasn't steady."

During an interview with RN 1 (who was Patient A's nurse at the time of the fall) on 3/16/11 at 2:38 PM, he stated "There was no formal fall assessment in the documentation I used. If a patient is admitted, there is a fall scale. There is only one place for us: a musculoskeletal assessment with charting by exception, and no formally documented plan."

The musculoskeletal assessment dated 9/11/10 at 1:50 PM for Patient A indicated the patient had steady gait and coordination.

During an interview with Charge Nurse (CN) 1 on 3/17/11 at 9:54 AM, she stated "We don't have care plans in the ED."

During an interview with the Medical Director on 3/23/11 at 10:40 AM, he stated "I think (Patient A) languished far too long in the ED without identified risks..."

During an interview with QS 1 on 4/28/11 at 1:18 PM, he stated "We don't have anything in the ED for a fall risk policy. In the absence of an ED policy/procedure, we assume the hospital policy/procedure covers the ED, by extension."

Based on interview and record review the facility failed to determine that less restrictive interventions were ineffective before resuming restraint use for one patient (Patient A),which had the potential to result in unnecessary restraint use.

Findings:

The facility policy titled "Restraints: Management of Non Violent, Non Self-Destructive Behavior" dated August 2008 indicated in part, "Restraint may be used only when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm."

The "24 Hour Restraint Flowsheet" dated 9/12/10 for Patient A indicated bilateral soft wrist restraints were removed at 8:00 AM. At 8:00 PM, twelve hours later, the patient was placed back in the restraints. No information was found specifying what less restrictive interventions had been tried and ineffective, or what the rationale was for not using alternatives to restraints, before reapplying the restraints.

During an interview with Registered Nurse (RN) 3 on 2/17/11 at 1:47 PM, she stated she put Patient A back in restraints because he was pulling on his intravenous line. RN 3 did not indicate why less restrictive interventions would have been ineffective for the patient.

Based on interview and record review the facility failed to modify a plan of care (POC) for one patient's (Patient A) after the use of restraints, which resulted in the lack of documenting the process of assessment, intervention, and evaluation of the restraint use on a POC.

Findings:

The facility policy titled "Restraints: Management of Non Violent, Non Self-Destructive Behavior" dated August 2008 indicated in part, "Restraint use must be included in the patient's plan of care...Plan of Care will be updated to include restraints and interventions..."

The clinical record for Patient A indicated he arrived in the Emergency Room (ER) on 9/11/10 at 1:00 PM. The patient was placed in bilateral soft wrist restraints at 6:45 AM. A "Nursing Initial/Continuing Assessment Form" was not modified to reflect the patient was in restraints. No nursing POC was found. Although technically admitted to the hospital on 9/12/10 at 3:00 AM, the patient didn't leave the ER until his death on 9/13/10 at 10:46 PM.

The "24 Hour Restraint Flowsheets" dated 9/12/10 and 9/13/10 for Patient A had sections to indicate that the POC had been initiated/updated on the "Interdisciplinary Patient/Family Health Education Records for inpatients, or the nursing flowsheet for outpatients. These sections were left blank for Patient A.

During an interview with Charge Nurse (CN) 1 on 3/17/11 at 9:54 AM, she was asked if Patient A had a written POC. CN 1 replied "We don't have care plans in the ER."

During an interview with Quality Staff (QS) 1 on 3/16/11 at 1:57 PM, he stated "For some reason they didn't have a treatment plan on (Patient A), a nursing care plan (NCP) for interventions. After a certain period of time they are supposed to initiate a NCP."

Based on interview and record review the facility failed to ensure restraints used for one patient (Patient A) were used in accordance with hospital policy, which resulted in a lack of obtaining a new order for each episode of restraint use, a lack of monitoring the patient's safety and comfort every two hours while in restraints, and a lack of debriefing after each episode of restraint use.

Findings:

The facility policy titled "Restraints: Management of Non Violent, Non Self-Destructive Behavior" dated August 2008 indicated in part, "A new order is required for each episode of restraint...The following monitoring of patients safety and comfort will be completed by a licensed staff member every 2 hours or more often as required by the patient condition:

a. Level of Consciousness/Orientation...
c. Criteria for Release
d. Assessment
1) Signs of any injury associated with the application of restraints
2) Comfort
3) Circulation
4) Edema
5) Elimination
6) Emotional Status
7) Nutrition/Hydration
8) Privacy/Dignity
9) Pulses
10) Repositioning/Body Alignment
e. Correct application of restraint
f. Circulation, range of motion in the extremities...

The following Quality data will be collected...Information obtained from debriefing after each episode (sic) restraint or seclusion..."

The "24 Hour Restraint Flowsheet" dated 9/12/10 for Patient A indicated bilateral soft wrist restraints were removed at 8:00 AM. At 8:00 PM, twelve hours later, the patient was placed back in the restraints. A new order for the subsequent restraint use was not found. Also, no continued need for restraint, criteria for release, or range of motion was specified on the flow sheet at 8:00 PM. And, the restraint flow sheet was blank from 10:00 PM on 9/12/10 until 4:00 AM on 9/13/10, when the patient was again noted to be in restraints. This showed a lack of documentation every two hours for 10:00 PM, 12 midnight, and 2:00 AM. No evidence of debriefing was found in the record.

During an interview with Registered Nurse (RN) 3 on 2/17/11 at 1:47 PM, she stated "I put restraints back on (Patient A, at 8:00 PM on 9/12/10)...I think he stayed in restraints until he went to the trauma bay (at 8:55 PM). I figured the next nurse would continue the restraint flow sheet." RN 3 did not indicate why she did not obtain a new order for the resumption of restraint use for Patient A.

During an interview with RN 5 on 3/23/11 at 9:10 AM, she stated she assumed Patient A's care in the trauma room (on 9/12/10 at 8:55 PM). RN 5 did not recall if Patient A was in restraints, but reviewed the record and could not find evidence the patient was taken out of restraints (that would justify the lack of documentation of monitoring) before the 4:00 AM notation indicating that the patient was back in restraints. "I suppose the one who took (the restraints) off should document it."

Based on interview and record review the facility failed to document restraints used for one patient (Patient A) were discontinued at the earliest possible time, which had the potential to result in extended use of restraints.

Findings:

The facility policy titled "Restraints: Management of Non Violent, Non Self-Destructive Behavior" dated August 2008 indicated in part, "The following monitoring of patients safety and comfort will be completed by a licensed staff member every 2 hours or more often as required by the patient condition...

b. Continued need for restraints"

The "24 Hour Restraint Flowsheet" dated 9/12/10 for Patient A indicated bilateral soft wrist restraints were removed at 8:00 AM. At 8:00 PM, twelve hours later, the patient was placed back in the restraints. No continued need for restraint was specified on the flow sheet from 8:00 PM until 8:15 AM on 9/13/10 when the restraints were removed, except at 4:00 AM on 9/13/10. At 5:05 AM the narrative nursing notes specified there was no movement to the patient's extremities. At 7:00 AM the narrative notes indicated the patient's pupils were fixed bilaterally.

During an interview with RN 5 on 3/23/11 at 9:10 AM, she stated she assumed Patient A's care in the trauma room (on 9/12/10 at 8:55 PM). RN 5 did not recall if Patient A was in restraints, but reviewed the record and could not find evidence the patient was taken out of restraints (that would justify the lack of documentation of continued need for restraints) after they were reapplied at 8:00 PM and before the notation on 9/13/10 at 4:00 AM that indicated the patient was in restraints. "I suppose the one who took (the restraints) off should document it."

Based on interview and record review the facility failed to document one patient's (Patient A)response to restraints, which had the potential to result in the lack of a well-reasoned plan for the continued use of the restraints.

Findings:

The facility policy titled "Restraints: Management of Non Violent, Non Self-Destructive Behavior" dated August 2008 indicated in part, "Progress notes will include patient's response to the treatment/interventions."

The clinical record for Patient A indicated he was placed in bilateral soft wrist restraints on 9/12/10 at 6:45 AM. The "24 Hour Restraint Flowsheet" dated 9/12/10 for Patient A indicated bilateral soft wrist restraints were removed at 8:00 AM. At 8:00 PM, the patient was placed back in the restraints until 8:15 AM on 9/13/10. No information was found indicating what the patient's response to the restraints was from 8:00 PM on 9/12/10 until 4:00 AM on 9/13/10.

During an interview with Registered Nurse (RN) 3 on 2/17/11 at 1:47 PM, she stated "I put restraints back on (Patient A, at 8:00 PM on 9/12/10)...I think he stayed in restraints until he went to the trauma bay (at 8:55 PM). I figured the next nurse would continue the restraint flow sheet." RN 3 did not indicate why she did not document the continued need for restraints for Patient A.

During an interview with RN 5 on 3/23/11 at 9:10 AM, she stated she assumed Patient A's care in the trauma room (on 9/12/10 at 8:55 PM). RN 5 did not recall if Patient A was in restraints, but reviewed the record and could not find evidence the patient was taken out of restraints (that would justify the lack of documentation of continued need for restraints) after they were reapplied at 8:00 PM and before the notation on 9/13/10 at 4:00 AM that indicated the patient was in restraints. "I suppose the one who took (the restraints) off should document it."

Based on interview and record review the facility failed to provide evidence two staff involved in restraints used on one patient (Patient A) had been trained and/or were current in training in the application restraints, monitoring, assessment, and providing care for a patient in restraints, which had the potential to result in inappropriate restraint use.

Findings:

The clinical record for Patient A indicated Registered Nurse (RN) 1 took over the care of Patient A, who was in bilateral wrist restraints, on 9/12/10 at 7:00 AM. At 8:45 AM, RN 1 removed the restraints. On 9/13/10 at 7:00 AM, RN 6 took over the care of Patient A, who was again in bilateral wrist restraints. At 8:14 AM, RN 6 removed the restraints.

On 4/26/11 at 10:30 AM Quality Staff (QS) 1 was asked for verification of training in restraint techniques for RN's 1 and 6. On 5/12/11 at 2:17 PM QS 1 indicated RN 1 did not have a current competency sheet and RN 6's competency sheet was dated 2007 and not current.

Based on interview and record review the facility failed to provide evidence two staff involved in restraints used on one patient (Patient A) had been trained and/or were current in training in techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint, which had the potential to result in knowledge deficits in these areas.

Findings:

The clinical record for Patient A indicated Registered Nurse (RN) 1 took over the care of Patient A, who was in bilateral wrist restraints, on 9/12/10 at 7:00 AM. At 8:45 AM, RN 1 removed the restraints. On 9/13/10 at 7:00 AM, RN 6 took over the care of Patient A, who was again in bilateral wrist restraints. At 8:14 AM, RN 6 removed the restraints.

On 4/26/11 at 10:30 AM Quality Staff (QS) 1 was asked for verification of training in restraint techniques for RN's 1 and 6. On 5/12/11 at 2:17 PM QS 1 indicated RN 1 did not have a current competency sheet and RN 6's competency sheet was date 2007 and not current.

Based on interview and record review the facility failed to provide evidence two staff involved in restraints used on one patient (Patient A) had been trained and/or were current in training in the use of nonphysical intervention skills before resorting to restraints, which had the potential to result in unnecessary restraint use.

Findings:

The clinical record for Patient A indicated Registered Nurse (RN) 1 took over the care of Patient A, who was in bilateral wrist restraints, on 9/12/10 at 7:00 AM. At 8:45 AM, RN 1 removed the restraints. On 9/13/10 at 7:00 AM, RN 6 took over the care of Patient A, who was again in bilateral wrist restraints. At 8:14 AM, RN 6 removed the restraints.

On 4/26/11 at 10:30 AM Quality Staff (QS) 1 was asked for verification of training in restraint techniques for RN's 1 and 6. On 5/12/11 at 2:17 PM QS 1 indicated RN 1 did not have a current competency sheet and RN 6's competency sheet was date 2007 and not current.

Based on interview and record review the facility failed to provide evidence two staff involved in restraints used on one patient (Patient A) had been trained and/or were current in training in choosing the least restrictive intervention based on an individualized assessment of the patient's medical or behavioral status or condition, which had the potential to result in the use of an overly-restrictive intervention.

Findings:

The clinical record for Patient A indicated Registered Nurse (RN) 1 took over the care of Patient A, who was in bilateral wrist restraints, on 9/12/10 at 7:00 AM. At 8:45 AM, RN 1 removed the restraints. On 9/13/10 at 7:00 AM, RN 6 took over the care of Patient A, who was again in bilateral wrist restraints. At 8:14 AM, RN 6 removed the restraints.

On 4/26/11 at 10:30 AM Quality Staff (QS) 1 was asked for verification of training in restraint techniques for RN's 1 and 6. On 5/12/11 at 2:17 PM QS 1 indicated RN 1 did not have a current competency sheet and RN 6's competency sheet was date 2007 and not current.

Based on interview and record review the facility failed to provide evidence two staff involved in restraints used on one patient (Patient A) had been trained and/or were current in training in the safe application and use of all types of restraints used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress, which had the potential to result in unrecognized distress related to restraint use.

Findings:

The clinical record for Patient A indicated Registered Nurse (RN) 1 took over the care of Patient A, who was in bilateral wrist restraints, on 9/12/10 at 7:00 AM. At 8:45 AM, RN 1 removed the restraints. On 9/13/10 at 7:00 AM, RN 6 took over the care of Patient A, who was again in bilateral wrist restraints. At 8:14 AM, RN 6 removed the restraints.

On 4/26/11 at 10:30 AM Quality Staff (QS) 1 was asked for verification of training in restraint techniques for RN's 1 and 6. On 5/12/11 at 2:17 PM QS 1 indicated RN 1 did not have a current competency sheet and RN 6's competency sheet was date 2007 and not current.

Based on interview and record review the facility failed to provide evidence two staff involved in restraints used on one patient (Patient A) had been trained and/or were current in training in clinical identification of specific behavioral changes that indicate that restraint is no longer necessary, which had the potential to result in extended use of restraints.

Findings:

The clinical record for Patient A indicated Registered Nurse (RN) 1 took over the care of Patient A, who was in bilateral wrist restraints, on 9/12/10 at 7:00 AM. At 8:45 AM, RN 1 removed the restraints. On 9/13/10 at 7:00 AM, RN 6 took over the care of Patient A, who was again in bilateral wrist restraints. At 8:14 AM, RN 6 removed the restraints.

On 4/26/11 at 10:30 AM Quality Staff (QS) 1 was asked for verification of training in restraint techniques for RN's 1 and 6. On 5/12/11 at 2:17 PM QS 1 indicated RN 1 did not have a current competency sheet and RN 6's competency sheet was date 2007 and not current.

Based on interview and record review the facility failed to provide evidence two staff involved in restraints used on one patient (Patient A) had been trained and/or were current in training in monitoring the physical and psychological well-being of the patient who is restrained, which had the potential to result in a lack of monitoring skills related to restraint use.

Findings:

The clinical record for Patient A indicated Registered Nurse (RN) 1 took over the care of Patient A, who was in bilateral wrist restraints, on 9/12/10 at 7:00 AM. At 8:45 AM, RN 1 removed the restraints. On 9/13/10 at 7:00 AM, RN 6 took over the care of Patient A, who was again in bilateral wrist restraints. At 8:14 AM, RN 6 removed the restraints.

On 4/26/11 at 10:30 AM Quality Staff (QS) 1 was asked for verification of training in restraint techniques for RN's 1 and 6. On 5/12/11 at 2:17 PM QS 1 indicated RN 1 did not have a current competency sheet and RN 6's competency sheet was date 2007 and not current.

Based on interview and record review the facility failed to document two staff involved in restraints used on one patient (Patient A) had been trained and/or were current in training in appropriate use of restraints, which had the potential to result in restraint use other than to ensure the immediate physical safety of the patient, a staff member, or others, and not discontinued at the earliest possible time.

Findings:

The clinical record for Patient A indicated Registered Nurse (RN) 1 took over the care of Patient A, who was in bilateral wrist restraints, on 9/12/10 at 7:00 AM. At 8:45 AM, RN 1 removed the restraints. On 9/13/10 at 7:00 AM, RN 6 took over the care of Patient A, who was again in bilateral wrist restraints. At 8:14 AM, RN 6 removed the restraints.

On 4/26/11 at 10:30 AM Quality Staff (QS) 1 was asked for verification of training in restraint techniques for RN's 1 and 6. On 5/12/11 at 2:17 PM QS 1 indicated RN 1 did not have a current competency sheet and RN 6's competency sheet was date 2007 and not current.

Based on interview and record review the facility failed to document information necessary to monitor the condition of one patient (Patient A), which resulted in knowledge deficits regarding vital signs (assessments of blood pressure, temperature, pulse, and respirations) and neuro checks (assessments made by a medical professional on someone with a head injury. Neuro checks should be performed once an hour for 24 hours).

Findings:

The facility policy titled "Fall Risk Assessment and Prevention" dated November 2008 indicates in part, "In the event that a patient should fall, the nursing staff, physician or other licensed provides, depending on clinical setting, will perform the following:...Obtain and record sitting/standing vital signs."

Narrative Nursing Notes (NNN) dated 9/12/10 at 7:05 PM indicated Patient A fell and sustained a laceration near the right eyebrow and was bleeding from the mouth. At 8:50 PM the patient was bleeding from the nose and mouth. He was moved to the trauma room. At 9:15 PM the patient was repeatedly suctioned due to blood in the mouth. He was determined to be a 9 on the Glasgow coma scale (GCS: 15 equals no impairment, 7 equals coma. The patient arrived at the facility with a GCS of 12). At 11:05 PM his consciousness remained altered with incomprehensible words and continued bleeding from the mouth. He required sutures to the head. At midnight the patient required oxygen due to decreased oxygen saturation (92-93%). At 12:05 AM on 9/13/10 an order for a CT scan (A computerized axial tomography scan is an x-ray procedure that combines many images to generate cross-sectional views and three-dimensional images of the internal organs and structures of the body) was obtained which revealed a subdural (beneath the outer membrane covering the brain) bleed. At 2:00 AM, FM 1 was called and agreed to intubation. Patient A ultimately passed away on 9/13/10 at 10:46 PM.

Although the NNN contained designated spaces for vital signs (v/s) at each opportunity of documentation, none were found at the time of Patient A's fall on 9/12/10 at 7:05 PM. V/S weren't documented until 11:00 PM. Neuro checks were not found in the record until 7:00 AM on 9/13/10, except for a reference to verbal response on 9/12/10 at 11:00 PM, and references to the GCS at 9:15 PM on 9/12/10 and 5:05 AM on 9/13/10.

During an interview with Registered Nurse (RN) 1 (who cared for Patient A up until the time of the fall) on 3/16/11 at 2:38 PM, he stated that after the fall the patient's "eyes were open but he was in a daze, couldn't verbalize or move his extremities, like in shock, a change in condition...V/S should be taken in the ED every 2-3 hours, that was in orientation but I'm not sure if it's a written policy." Regarding neuro checks, the RN replied "I don't know for sure, at least every two hours times four for a change in level of consciousness."

During an interview with RN 3 (who cared for Patient A from the time of the fall on 9/12/10 at 7:05 PM until 8:55 PM when he went to the trauma room) on 2/17/11 at 1:47 PM, she stated she did not remember if she documented neuro checks or vital signs for the patient.

During an interview with RN 5 (who cared for Patient A in the trauma room along with her partner RN 7 from 9/12/10 at 8:55 PM until 9/13/10 at 7:00 AM) on 3/23/11 at 9:10 AM, she stated there was usually another v/s sheet (but no other v/s sheet was found for Patient A during that time period). Regarding neuro checks, RN 5 indicated "Because we received (Patient A) from (another part of the ED), we had to continue that type of charting. When they decided to admit him, I could start the new charting, or start it at change of shift (at 7:00 AM)." RN 5 further indicated that with the type of charting she was using, documentation of neuro checks would have to be in the narrative notes, "or somewhere else. Sometimes when there are two (nurses), you think the other one did it."

During an interview with RN 7 on 4/25/11 at 1:20 PM, she stated regarding neuro checks, "We do them every hour on intubated and altered level of consciousness patients but the ED documents aren't the best. When someone will be admitted, when the next shift comes on, they document on a better form. We've been fighting for a better form for a while." RN 6 also stated "I would expect v/s at least every two hours. That form is a continuation page. The main ED flow sheet has areas for v/s (but this flow sheet indicated "see nursing notes" for further v/s).

During an interview with Charge Nurse (CN) 1 on 3/17/11 at 9:54 AM, she was asked when neuro checks should be done. CN 1 replied "It all depends. If someone falls and is out of it, from my personal experience, unequal pupils, loopy, I do them every 15 minutes. I'd have to look up the actual policy."

Quality Staff (QS) 1 was asked on 1/20/11 at 11:55 AM for all documentation of neuro checks for Patient A after the above fall. On 3/16/11 at 1:57 PM, 4/26/11 at 10:30 AM, 4/28/11 at 1:18 PM and again on 5/12/11 at 3:39 PM QS 1 was asked for evidence of a facility policy regarding the expectation of the frequency of documentation of v/s and neuro checks. This information was not provided.

Based on interview and record review the facility failed to integrate the services of its Emergency Department (ED) with other departments, for one patient (Patient A), which resulted in the facility not making the full extent of its patient care resources available to assess and render appropriate care to an emergency patient in the areas of fall prevention and monitoring the condition of the patient.

Findings:

The facility policy titled "Fall Risk Assessment and Prevention" dated November 2008 indicates in part, "...a Fall Risk Assessment is completed and preventative measures are implemented based on the level for risk."

On 9/13/10 at 6:39 PM the facility reported Patient A had a fall on 9/12/10 at 7:05 PM while in the ED. The patient subsequently passed away on 9/13/10 at 10:46 PM from injuries sustained during the fall. At that time the patient had been in the ED for 57.5 hours. The only fall risk assessment found in the record was dated 9/13/10 at 7:00 AM.

On 1/20/11 at 11:55 AM Quality Staff (QS) 1 was asked for evidence of a timely fall risk assessment and/or a fall prevention care plan for Patient A. On 3/16/11 at 1:57 PM QS 1 stated "For some reason they didn't have a treatment plan on (Patient A), a nursing care plan for interventions. After a certain period of time they are supposed to initiate a nursing care plan."

During an interview with Registered Nurse (RN) 3 on 2/17/11 at 1:47 PM, she stated Patient A "definitely was a high fall risk because he wasn't steady."

During an interview with RN 1 (who was Patient A's nurse at the time of the fall) on 3/16/11 at 2:38 PM, he stated "There was no formal fall assessment in the documentation I used. If a patient is admitted, there is a fall scale. There is only one place for us: a musculoskeletal assessment with charting by exception, and no formally documented plan."

The musculoskeletal assessment dated 9/11/10 at 1:50 PM for Patient A indicated the patient had steady gait and coordination.

During an interview with Charge Nurse (CN) 1 on 3/17/11 at 9:54 AM, she stated "We don't have care plans in the ED."

During an interview with the Medical Director on 3/23/11 at 10:40 AM, he stated "I think (Patient A) languished far too long in the ED without identified risks..."

During an interview with QS 1 on 4/28/11 at 1:18 PM, he stated "We don't have anything in the ED for a fall risk policy. In the absence of an ED policy/procedure, we assume the hospital policy/procedure covers the ED, by extension."

The facility policy titled "Fall Risk Assessment and Prevention" dated November 2008 indicates in part, "In the event that a patient should fall, the nursing staff, physician or other licensed provider, depending on clinical setting, will perform the following:...Obtain and record sitting/standing vital signs."

Narrative Nursing Notes (NNN) dated 9/12/10 at 7:05 PM indicated Patient A fell and sustained a laceration near the right eyebrow and was bleeding from the mouth. Although the NNN contained designated spaces for vital signs (v/s) at each opportunity of documentation, none were found at the time of Patient A's fall on 9/12/10 at 7:05 PM.

During an interview with Registered Nurse (RN) 1 (who cared for Patient A up until the time of the fall) on 3/16/11 at 2:38 PM, he stated that after the fall the patient's "eyes were open but he was in a daze, couldn't verbalize or move his extremities, like in shock, a change in condition."

During an interview with RN 3 (who cared for Patient A at the time of the fall on 9/12/10 at 7:05 PM) on 2/17/11 at 1:47 PM, she stated she did not remember if she documented vital signs for the patient.