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Based on policy review, medical record review and interview, nursing staff failed to supervise, document and evaluate the care provided to Patient #1. This could potentially contribute to inadequate treatment and/or an adverse patient outcome.

Findings include:

Review on 01/25/18 of policy "Fall Management and Safety Protocol" last revised 06/17 indicates if a patient is identified as a moderate or high risk for falls, a red alert bracelet will be applied as a reminder for the staff. If a patient is a high risk for falls, post the appropriately numbered "Falling Star" sign outside the patient's door. Yellow socks will be placed on patients assessed at high risk for falls. Document education for the patient. If a fall occurs, document a post fall assessment of the patient including signs of injury, vital signs and neurological checks if potential head injury every 15 minutes x 4, then as ordered by physician. Document an updated patient assessment and other pertinent information.

Review on 01/25/18 of medical record revealed that Patient #1 presented to the Emergency Department (ED) with the complaint of dizziness and weakness on 10/29/17 at 01:23 PM. At 01:30 PM Patient #1 is assessed as a fall risk. Patient #1 sustained a fall after being ambulated to bathroom and left alone in bathroom by ED staff. No documentation was found in the ED record indicating fall prevention interventions were implemented and/or education was provided to Patient #1. No documentation was found in the ED record to indicate post fall assessments were performed by nursing staff per facility policy.

Interview on 01/25/18 at 10:00 AM with Staff (A), Director of Quality/Patient Safety and Staff (B), Vice President of Quality verified these findings.