HospitalInspections.org

Based on document review, medical record review and interview, 1) 3 of 5 (Patient # 2, Patient # 3, and Patient #4) medical records lacked appropriate fall risk documentation. 2) Nursing staff in the Emergency Department were not aware of fall risk interventions available for patients and staff lacked annual fall risk education. This could lead to patients having an increase risk to fall and untoward outcomes.

Findings regarding (1) include:

-- Review of the facility's policy and procedure titled "Fall Management," reviewed 6/2021, indicated that every patient admitted to the hospital including those patients receiving services within the Emergency Department, will be assessed in order to determine the patient's potential for falls. There are 6 areas to review including history of falling, secondary diagnosis, need for ambulatory aids, intravenous therapy/saline lock use, gait and mental status. In addition, universal fall precautions will be followed for every patient.

-- Review of Patient #2's (84 year old) medical record revealed he presented to the Emergency Department on 1/9/2024 at 7:37 am, with a chief complaint of a fall and low back pain. Nursing documented fall risk "none identified".

-- Review of Patient #3's (82 year old) medical record revealed he presented to the Emergency Department on 1/9/2024 at 9:32 am, with a chief complaint of positive COVID, fever, weakness, and not eating. Patient history of atrial fibrillation on blood thinners. Nursing documented fall risk "none identified".

-- Review of Patient #4's (69 year old) medical record revealed she presented to the Emergency Department on 1/9/2024 at 6:03 am, with a chief complaint of pain in the right leg and dizziness. Patient had a history of motor vehicle accident two weeks prior and hypertension. Patient stated "I feel like I am going to pass out." Nursing documented fall risk "none identified".

-- Per interview of Staff A, Interim Director of Emergency Department/Assistant Director of Nursing Services on 1/9/2024 at 9:21 am, there is a fall risk scale included in the triage portion of the medical record. This scale is similar to the Morse Fall Scale (assessment tool that predicts the likelihood that a patient will fall). Staff A acknowledged the above findings.

Findings regarding (2) include:

-- Review of the facility's policy and procedure "Fall Management," reviewed 6/2021 indicated universal fall precautions will be used for all patients regardless of fall risk (for example: secure call bell within reach, instruct patients to request help when getting out of bed, hourly rounding, etc.). Moderate fall risk precautions include universal precautions in addition to other precautions (for example fall armband and signage, alarm bed/chair, room close to nursing station, etc.).

-- Per interview of Staff A, on 1/9/2024 at 9:21 am, patients identified as a fall risk or with confusion are usually placed in the 3 rooms closest to the nurses station. There are a number of Posey chair and bed alarms available in the department which should be utilized more. If necessary, staff will call the supervisor to get a sitter assigned to the patient. Patients identified as a fall risk should have a yellow wrist band, falling leaf above the door and fall risk noted on the white board in their room.

-- Per interview of Staff B, Registered Nurse on 1/9/2024 at 10:15 am, if patients are a fall risk they should have a yellow fall risk bracelet, call light within reach, siderails up. Many times, the patient will have someone with them. There is no identifying information outside the room about fall risk or in the room on the whiteboard. Staff B, was unsure of scoring patients for fall risk. Staff B, indicated possibly receiving HealthStream education on falls annually and the policy and procedure is on the intranet.

-- Per interview of Staff C, Registered Nurse on 1/9/2024 at 10:30 am, when assessing a patient for their fall risk, Staff C considers their diagnosis, chief complaint, age, and location in the Emergency Department. Preventative measures include siderails, call bell within reach, make sure the room is clean, frequent checks on patient and a sitter if needed. There are 2 rooms available where patients are visible to the nurse's station. They do not have bed or chair alarms, Staff C knows they exist but has never seen them in the Emergency Department. There are no HealthStream education or competencies pertaining to falls that Staff C is aware of. If there is a fall in the department staff may be notified during patient handoff. Staff C is not aware of any morning safety huddles.

-- Per interview of Staff D, Director of Staff Development and Occupational Health on 1/10/2024 at 9:35 am, staff are provided safe patient handling along with general fall guidelines at time of hire. There is no annual falls education provided. There is presently no Falls committee. Falls would be addressed at the Special Attention Review Committee.

-- During interview of Staff A, on 1/10/2024 at 1:55 pm, he/she/they acknowledged the above findings.

Based on medical record review, document review and interview, in 1 (Patient #5) of 3 medical records, 3 medication orders were missing a provider's authentication. This could lead to a lack of provider oversight and untoward patient outcomes.

Findings include:

-- Review of Patient #5's medical record showed medication orders for Colace 200 milligrams by mouth, twice a day, Prednisone 40 milligrams by mouth, one time order and Prednisone 20 milligram by mouth, twice a day. These orders were entered and acknowledged (on 1/6/2024) by Staff E, Registered Nurse. As of 1/9/2024 these medication orders were not signed/authenticated by the provider.

-- Per review of hospital's policy and procedure titled "Medication Management," last approved 10/7/2022, "medication orders must be signed by a provider".

-- During interview of Staff E, Registered Nurse on 1/9/2024 at 1:30 pm, he/she/they acknowledged the 3 medication orders (above) lacked provider authentication.

-- Per interview of Staff F, Pharmacist, on 1/10/2024 at 11:25 am, providers communicate telephone orders to pharmacists and registered nurses for medical record entry. Once telephone orders are verified by a pharmacist the medications are available to be administered to the patient. The pharmacist indicated the ordering provider is expected to sign/authenticate all orders within 48 hours.

-- During interview of Staff G, Physician, on 1/10/2024 at 2:45 pm, he/she/they communicate non-emergent telephone orders to staff. These should be entered into the medical record as telephone orders. When entered as telephone orders, providers receive an alert to sign/authenticate the order.

-- During interview of Staff H, Pharmacy Director, on 1/12/2024 at 11:15 am, he/she/they confirmed the above medication findings. He/she/they indicated these orders were entered by Staff E, on 1/6/2024 as written orders instead of telephone orders. Staff H indicated telephone orders trigger an alert in the medical record for the provider to sign/authenticate the order within 48 hours.