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Based on findings from medical record (MR)review, document review, and interview, the facility's quality assurance performance improvement (QAPI) program lacked adequate follow through of corrective actions identified during its investigation of an adverse event. Additionally no monitoring was put in place to evaluate effectiveness of corrective actions. This could lead to other similar adverse events.

Findings include:

--Per MR review, a 91-year-old ED patient (Patient #1) identified as a risk to fall was found lying at the foot of her bed, face down in a large pool of blood, awake and moaning. Patient #1 was subsequently admitted to the hospital with a left eyebrow laceration, intracranial hemorrhage and left hip fracture. See citation A1101 regarding details of this adverse event.

-- Review of the hospital investigation, dated 6/19/17 revealed the hospital identified corrective actions to address causes of the adverse event. Some of the corrective actions included:

1) Education via email and a staff meeting regarding the proper interventions for high risk fall patients was completed on 7/31/17 for both licensed and unlicensed staff.
2) A supply of bed alarms will be housed in the ED for at risk patients in the ED
3) Bed alarms will be placed on stretchers of patients who are identified as high risk for a fall.

However, these corrective actions are not consistent with hospital P&P. The hospital P&P for fall prevention in the ED does not delineate between "high risk to fall" and "risk to fall." The use of inconsistent terms has led to inconsistent implementation of fall prevention interventions in the ED.

For example, During interview of Staff A, ED RN on 8/29/17 at 8:30 am, when asked about bed alarm use, he/she stated that only the highest risk patients get a bed alarm. He/she stated the fall prevention P&P identifies which patients are classified as highest risk. That is not accurate. The ED falls P&P does not separate levels of fall risk.

Another example on 8/28/17 at 9:55 am, Staff B, RN, Shift Coordinator was observed providing care to a patient in the ED. The patient was identified as "risk to fall." The patient had a yellow bracelet and yellow non-skid socks in place. When asked about bed alarm use, he/she indicated if a family member is present (and there was one with Patient #2) a bed alarm does not need to be applied to the ED bed. However per interview of Staff C, ED RN, he/she stated that all patients identified as a fall risk should have a bed alarm attached to the bed, regardless of whether family is present at the bedside or not. Staff do not have a clear understanding of fall prevention practices.

-- Additionally the documented investigation lacked any plans to monitor the effectiveness of the new interventions to be implemented.

-- Staff were educated regarding fall risk which was completed on 7/31/17. MR reviews during the survey found a lack of documentation of fall risk assessments and interventions. See citation A1101 regarding details of thees documentation lapses.

Based on findings from document review, medical record (MR) review, and interview, the facility failed to ensure that all patients received care that was consistent with prevailing standards of practice. Specifically an emergency department (ED) patient (Patient #1) identified as a risk to fall, fell and sustained injuries. Also 5 of 5 ED MRs (Patients #9, #6, #3, #10 and #4) lacked adequate documentation related to falls (i.e., fall risk assessment and/or fall prevention interventions.)

Findings include:

-- Review of the facility policy and procedure (P&P) titled "Fall Prevention Program/Patient Falls-ED Addendum," last revised 3/2014, directed ED nursing staff to perform a fall risk assessment on all patients presenting to the ED and document the findings in the triage nursing notes. All patients who are at risk for falling will be identified and the fall prevention plan should be implemented. The following actions should be implemented for all patients identified as at risk for falling:

* A yellow "FALL RISK" wrist band will be applied to the patient
* When possible place the patient in a room visible to the nurses station
* One or two side rails up on stretcher
* Bed in low position and brakes on
* Call bell in reach and patient/family educated on it's use
* Hourly monitoring by ED staff; one to one monitoring if necessary
* Provide non-slip slippers
* Staff remains with patient during toileting

-- Per MR review, Patient #1, a 91-year-old female, presented to the ED on 6/16/17 at 4:44 am with a chief complaint of prolapsed rectum and uterus. She was triaged at 4:55 am and nursing documentation revealed a history of dementia. A Fall Risk Assessment was completed which identified risk factors as the patient's age and history of falls. Interventions documented were, bed in low position, siderails up and call bell in reach. At 6:29 am nursing documentation revealed the patient was confused with dementia and incontinent of urine. At 7:15 am nursing documented the surgeon was at the bedside attempting prolapse repair and the patient was yelling out in pain. New physician orders were implemented. The patient was medicated with Fentanyl and Ativan. Nursing documented at 8:42 am that Patient #1 was calm and resting and vital signs were stable. Vital signs were repeated again at 9:01 am. The next documentation by nursing was at 9:20 am indicating the patient was found lying at the foot of the bed, face down in a large pool of blood, awake and moaning. Patient #1 was moved to a trauma room and later was admitted with a left eyebrow laceration, intracranial hemorrhage and left hip fracture.

-- Per interview of Staff F, ED RN who provided care to Patient #1 on 9/13/17 at 8:42 am, Patient #1 came to the ED from a nursing home. She was complaining of pain due to her prolapsed rectum and uterus. Patient #1 was confused at times and was incontinent of urine. Staff F indicated he/she performed frequent bed checks. Her bed was in low position and side rails were up. Staff F could not recall if the yellow fall risk bracelet or non-slip slippers had been applied to the patient. When asked, he/she indicated a bed alarm was not placed under the patient.

-- During interview of Staff A, ED RN who provided care to Patient #1 on 8/29/17 at 8:30 am and 9/13/17 at 9:00 am, he/she took report from the night nurse who had identified Patient #1 as a risk to fall. Staff A stated that he/she and the nurses aid were in the room frequently checking on Patient #1. The ED became very busy and 4 patients came in from a motor vehicle accident. At approximately 9:10 am Staff A looked in on Patient #1 and the patient was resting quietly in bed. At approximately 9:20 am, the nurses aid found Patient #1 on the floor. Staff A indicated he/she was not sure what fall interventions were implemented for Patient #1. Staff A could not recall if Patient #1 had a yellow fall risk bracelet or non-slip slippers on. When asked, Staff A indicated a bed alarm was not placed on the bed. Staff A stated that only the highest risk patients get a bed alarm. He/she stated the fall prevention P&P identifies which patients are classified as highest risk.

-- Per interview of Staff H, Nursing Assistant on 9/14/17 at 1:00 pm, he/she spoke with Patient #1 and "she seemed a little confused but not bad." He/she does not remember if the yellow fall risk bracelet or non-slip slippers were in place. The patient was waiting for a surgeon to come and examine her. Staff H indicated she entered the room and found Patient #1 standing next to the bed and needing to go to the bathroom. Staff H assisted the patient back to bed and notified Staff A about the incident. The patient was then placed on the bedpan several times but was unable to urinate. The surgeon came to see the patient, but was unable to perform the procedure due to the patient's pain. Staff A gave Patient #1 pain medications and turned the lights off to help her rest. The next time he/she checked, Patient #1 was sleeping. A short time later when Staff H went to check the patient, she was found on the floor.

Patient #1 was found standing next to the bed. No additional interventions were put in place to prevent a fall (for example, bed alarm, place closer to nurses station or one to one monitoring.)

-- Per review of Patient #9's MR (85 year-old male), he was triaged on 8/15/17 at 7:30 pm with a chief complaint of dizziness, weakness and near syncope. There was no documentation of a Fall Risk Assessment or fall prevention interventions implemented.

-- Per review of Patient #6's MR (84 year-old female), she was triaged on 8/28/17 at 8:17 am with a chief complaint of a fall. Nursing documentation at 8:40 am, under Fall Risk Assessment, indicated fall risk assessment completed. Risk factors identified included patient age greater than 65, history of fall and impairment of mobility. Fall intervention initiated, patient on stretcher, side rails up x 2, bed in low position, brakes on, call light in reach. Instructed patient to not get up without assistance. There was no documentation regarding fall bracelet or non-slip slippers.

The same lack of adequate documentation related to falls was found in MRs for Patient #3, date of service - 8/1/17; Patient #10, date of service - 8/15/17; and Patient #4, date of service - 8/27/17.

-- During interview of Staff G, ED Nurse Manager on 8/28/17 at 2:30 pm, he/she acknowledged the above findings.