HospitalInspections.org

Based on clinical record review and staff interview, the hospital failed to ensure that 1 of 2 patients experiencing a fall in the ED (Patient #1) received care based on their needs. This has the potential to affect the entire community of patients who are served by this ED, who experience fall risk factors.

Findings include:

Record review was conducted on 8/6/13/ and 8/7/13.
Patient #1 came into the ED by ambulance from assisted living facility on 5/7/13 at 8:15 p.m. with mental status changes and abdominal pain with vomiting.

Review of the triage assessment done by RN B on 5/7/13 at 9:18 p.m. listed the patient as needing "urgent" care, being unable to describe pain and having occasional restless movement. The triage assessment documents no evidence of a fall risk assessment for Patient #1. .

Review of the ED "Assessment Adult" done at 5/7/13/at 9:18 p.m. reflects that this patient wears glasses, is alert but not oriented to place or time, and is anxious, restless and uncooperative with slurred speech. Under "standard safety" in the "Assessment Adult", it documents "bed in low position, call device within reach, ID band check, wheels locked." There is no documented evidence of siderails use, and not known if patient understands the location or use of a call light system, when this patient is documented as being not oriented to surrounding. There is no documentation of assessment for fall risk, even though safety risk factors are identified.

This patient had an unwitnessed fall from the ED cart at 10:15 p.m. lacerating the 5th digit of left hand requiring stitches.

Interview with ED Staff Nurse B, responsible to the care of Patient #1, was conducted on 8/6/13 at 10:02 p.m. by telephone. ED RN B stated that when patient arrived in ED, patient was "confused and alert to name only and was restless the whole time" while in the ED. RN B stated that she triaged the patient, but did not flag this patient as a fall risk. She stated that the patient was put into a room that was not within visual range of the nursing station, but that when she left the room, Patient #1's daughter was present in the room. She did not remember telling the daughter to provide notice to ED staff when having to leave room. RN B stated that she was alerted to fall when the x-ray technician walked by the room, and saw patient on the floor. She stated that no one was in room when patient fell, and does not know when patients's daughter left room.

In interview with Director of ED A on 8/7/13 at 10 a.m., she stated that the hospital has a falls prevention protocol that is not used in the ED. Director A stated that the neither the nursing triage assessment nor the ED nursing assessment uses a fall risk scale to institute minimum fall risk prevention protocol used in the hospital in-patient units. Director A stated that the ED has 2 rooms that can be used to keep patients in visual range of the nursing station, but that these rooms were full when Patient #1 came into the ED.