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Based on document review, policy review, and staff interview the facility failed to perform a reassessment and medical screening on a patient who experienced a fall in the emergency department during their discharge from the facility.

Findings were:

Medical record review for patient #1 on 4/16/19 and 4/17/19 in the conference room at the facility revealed patient #1 arrived by ambulance and was treated in the emergency room on 3/7/19 for a complaint of chest pain. Patient #1 was seen by the emergency room physician and treatment was provided based on x-ray findings, laboratory findings, and patient assessment. Emergency room physician documented in medical record under Review of Systems: Pt is a poor/unreliable informant due to clinical condition. Supplemental information was collected from EMS medical records. Medical History: Alzheimer's disease; atrial fibrillation; bipolar disorder; dementia; depression; hypercholesterolemia; hypertension; seizure; thyroid disease. Physical Examination: Musculoskeletal: No tenderness, no swelling. Order was written to discharge patient and return patient to the nursing home at 6:57 pm on 3/7/19. Report was called to the nursing home at 6:29 pm by the day emergency nurse (staff #2). Staff #2 documented in the medical record the patient was discharged by ambulance stretcher back to the nursing home on 3/7/19 at 6:30 pm. Patient remained in the emergency department until staff from the nursing home arrived to transport patient back to the nursing home at 7:59 pm. During the transfer to the wheelchair from the stretcher by the hospital and nursing home staff the patient fell to the floor and her left leg was bent under her right leg. Patient#1 complained of pain to her knee on the left leg. Discharge Disposition: Skilled Nursing Facility-03 ED Departure date/time: 03/07/2019 20:27.

Documentation in the medical record by staff #3 stated "3/7/19: 19:59 CST; Pt with 4 staff members attempting to assist pt to WC. After attempting to stand, pt slides down on 2 staff members legs to floor. Pt did not fall." "3/7/19: 20:00 CST; pt transferred to WC with difficulty. Assisted by ER staff to lift."

No documentation in the medical record for patient #1 regarding assessment by the nursing staff or medical staff post patient fall while transferring to wheelchair.

Review of facility followup of the fall that was performed on 3/12/19 states in part "At this time, XXXXX RiskMaster was received for the fall and investigated. It was determined that the patient had been transferred to the Nursing Home care providers, and although we assisted, this was not a fall that required intervention or investigation. Recommendation was made to XXXXXX leaders that they ensure all staff have training on Be Safe lift equipment, and to encourage them to use it whenever they need to assist-even in this instance." "Staff documented their involvement in the RiskMaster but did not make medical note-while the patient was still in the facility, the nursing home staff had received report and were overseeing her care at this point. Optimally, since our facility was involved in offering assistance, it would have been prudent to document the fall and information following the fall. In one witness statement, it is noted that a provider also assisted, but does not document a follow-up assessment. It is also noted the patient was complaining of pain to legs and back when moving on the bed, prior to movement to the wheelchair. There was no report of increased pain/discomfort nor physical deformity following the fall. On the contrary, the healthcare team that was in possession of her care at that time also did not request assessment, did not perform assessment that evoked a marked deviation from prior status to request emergency intervention for the same." "Summary of findings: Overall, staff worked together with another facility to assist the patient in transfer to a wheelchair. At this time we have determined this to be a fall occurring after transfer to an outside healthcare facility. We will make recommendations for improvement, but do not feel this meets criteria for sentinel event reporting."

Facility policy titled "Falls Risk Protocol" states in part "Definition: A fall is defined as "an incident where a patient is on the ground secondary to an unplanned event." For example, if the floor was not where the patient intended to be, then it is a fall regardless of how he/she got there including falls, slid down the wall, lowered by staff, etc."

Facility policy titled "Discharge of Patient from the ED" states in part "Policy: The patient is discharged in stable condition upon order from the physician after all diagnostic and therapeutic procedures are completed. Procedure: H. Assist the patient to dress, if necessary. I. Assist patient into wheelchair, if necessary. K. Escort to waiting area or vehicle, if necessary."

Facility policy titled "Patient Assessment & Reassessment" states in part "Procedure: B. Reassessment: Patients shall be reassessed as necessary and always prior to discharge. 5. Recheck of any abnormal physical findings."

Facility policy titled "Medical Screening in the Emergency Department" states in part "To ensure that a Medical Screening Exam is performed on all persons presenting to XXXXXXX seeking emergency treatment, that are not scheduled. A medical screening is performed regardless of a person's ability to pay, sex, race, creed, or religious belief. A Physician and/or Advanced Practice Clinician must perform the Medical Screening Exam. The Medical Screening exam will include, but is not limited to, the history of the patient's current complaint, and any ancillary services routinely available to the Emergency Department to determine if an Emergency medical condition exists."

In an interview with staff #3 on 4/16/19 at 4:15pm she stated she was present the evening patient #1 was discharged from the emergency room. She stated that she did not know the abilities of the patient in transferring to a wheelchair. She stated the patient's vital signs were good. She further stated the nursing home sent a young guy and a young girl with a transport van and the patient wheelchair (WC). She stated she helped the guy from the nursing home turn the patient to side and assist in transferring to WC. She stated the patient started sliding and she got hospital socks to put on patient and stood patient up again. She stated as they started to pivot the patient the patient started sliding again and said she couldn't stand any longer and the guy from the nursing home said he had her and the patient slid down their legs to the floor. She stated the patient had her left leg bent under the right knee and was complaining of pain. She stated when she straightened the patient's left leg out she said it felt better. She said she called for the other nurse in the department and the X-Ray technician and ER physician who all came in and helped get the patient on a sheet and assisted in putting her in her wheelchair. She stated the WC seemed small for a patient the size of patient #1. She stated the patient was crying and kept apologizing for causing so much trouble. She stated the young guy from the nursing home said "we should have brought her lift". She stated although the physician helped to transfer the patient to the WC from the floor that he never assessed the patient and I would find no documentation of assessment in the medical record of the patient post fall. She stated when the patient uses a hoyer lift at the nursing home the staff usually bring a sling from the nursing home to use for transferring the patient. She stated they did not have a hoyer lift in the emergency department but had one on the medical surgical floor they could use when needed.

In an interview with staff #4 on 4/16/19 at 5:35 pm he stated he was an X-Ray tech in the facility. He stated he was asked to assist in transferring patient #1 from the floor into her WC. He stated the patient kept saying she was sorry she fell and was so much trouble. He stated patient #1 did not complain of any pain while he was in the room.

In an interview with staff #5 on 4/17/19 at 10:08 am by telephone stated she was on duty in the emergency room (ER) as the second nurse the evening patient #1 was being discharged. She stated she was in a different room taking care of a patient when staff #3 called for help in room 1. She stated the patient was on the floor with one leg bent under the other. Other staff were trying to get the patient off the floor with a sheet under the patient and the nursing home staff was there also. She said the patient apologized for being trouble. She stated patient #1 said "That feels better" after she was lifted off the floor. She stated the patient did not complain of pain while she was in the room assisting the other staff. She further stated that the ER physician for the evening was in the room helping to assist to lift the patient off the ground.

In an interview with staff #2 she stated she cared for the patient until her shift ended at 7:00 pm and the nursing home was not there yet to pick up patient #1. She stated patient #1 has dementia and is not competent to sign for herself so she had called report to the nursing home prior to leaving her shift. She further stated care for the patient is transferred to the nursing home staff when they arrive to pick up the patient and the ER staff assist the nursing home staff if needed in transferring the patient. She further stated if a patient fell in one of the rooms the patient should be assessed by the doctor before they continued with the discharge of the patient.

In an interview with the ER physician, staff #6 on 4/18/19 at 8:25 am he stated he heard a commotion in the room patient #1 was in and went in to see what was going on. He stated 2 people from the nursing home were attempting to transfer the patient to a WC. Patient #1 said her legs were weak and the patient went down to the floor. He stated the patient kept saying she was sorry to bother them so much. He stated the patient did not complain of pain while he was in the room so he did not perform an assessment on her because she never complained of pain and no one asked him to assess her before discharge.