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Based on record review, review of facility incidents/events, and staff interviews, the hospital failed to ensure a safe setting/environment for 1 of 1 patient (Patient #11) who sustained minor injuries from a fall off an interventional radiology table. Failure to assure patient safety with any procedure has the potential to place patients at risk for injury.

Findings include:

Review of medical records including surgical, inpatient, outpatient, and incident reports, identified Patient #11 experienced a fall from an interventional radiology (IR) table.

Review of Patient #11's closed record occurred on March 24-25, 2025. The record identified an operative report dated 01/19/2025. The operative report identified: 2:40:53 p.m. the patient was positioned prone (on the stomach) with arms up by the head. Arm boards in place to keep arms from falling off the side. Versed (sedation medication) 2 milligrams was given intravenously (IV) at 2:45 p.m. and Fentanyl (pain medication) 1 microgram IV at 2:46 p.m. At 2:47 p.m. documentation identified the patient rolled off the procedure table on to the floor. The provider immediately evaluated the patient and identified small abrasions to the left elbow, back, and shoulder. Staff lifted the patient with a blanket to a cart and further monitored. The patient had a computed tomography scan (CT) of the head completed with normal findings and returned to the medical floor with further monitoring.

Review of an event report completed 01/19/25 identified, "Patient was positioned prone on IR procedure table. Patient was prepped and draped, arms were up by his head with arm boards and strap to hold his arms up. Shortly after giving initial sedation while staff was preparing supplies for procedure, patient adjusted his position and the shift in body weight caused him to roll off the table. . . ."

Review of the follow-up assignment notes regarding the incident identified recommendations of the following:
* Additional safety straps (placed to not interfere with the procedure and access to the patient).
* Have the necessary supplies pulled prior to putting the patient on the table.
* Get a quote for some additional arm boards.
* Instruct that a staff member must be at the table side when the patient is on the table.
* Consider including a CNA (certified nurse assistant) with the on-call crew.

During interview on 03/25/2025 at 3:00 p.m., a registered nurse (RN) (#1), present at the time of the incident, stated the patient showed no signs of restlessness, so they had no concern of the possibility of the patient rolling off the table at the time and confirmed staff did not place straps around the patient for safety. The RN (#1) described the strap used with the arm boards went over the arm boards to help them be more stable but did not go around the patient's arms. The RN (#1) stated staff discussed the use of straps in a department meeting after the incident occurred.

During interview on 03/25/2025 at 8:00 a.m., an administrative staff member (#2) stated after the incident, facility staff completed a department huddle with staff from the interventional radiology department regarding not leaving the bedside when a patient is on the procedure table, and use of straps on the patient, but facility did not document this discussion. Upon request, the administrative staff member (#2) was not able to provide a policy/procedure regarding safety of the patient during interventional radiology procedures, use of straps, or staff remaining at the bedside.

During interview on 03/25/25 at 8:10 a.m., a radiology technician (RT) (#3) confirmed a department huddle post incident with discussion including use of straps on a patient during procedures for safety. The RT (#3) stated staff should use table straps if the patient is restless, has a large body mass, and considering the amount of sedation used, and confirmed the huddle discussion also included never leaving the patient bedside.