HospitalInspections.org

Based on medical record (MR) review, document review, and interview, the facility failed to maintain a safe environment for patients.

This failure placed all patients at risk for serious harm, injury, or death.

Findings:

- The facility failed to assess patients for fall risk upon Emergency Department (ED) presentation.
(See Tag A-0144)

Based on medical record (MR) review, document review and interview, the facility failed to assess patients for fall risk upon Emergency Department (ED) presentation, in six (6) of fifteen (15) MRs.

The facility's failure to assess, identify, and implement preventative fall measures resulted in a serious adverse outcome for Patient #1, and placed all patients at risk for serious harm, injury, or death.

Findings:

The facility policy and procedure (P&P) titled, "Nursing Management of Fall and Injury Reduction in the Adult Patient in the Emergency Department [ED]," last dated 1/2024, directed the ED Registered Nurse (RN) to "complete Risk Screen: Kinder 1 Fall Risk Assessment." The policy stated the "Purpose" of the Fall Risk Assessment was "the responsibility of the Emergency Department (ED) Registered Nurse (RN) in identifying patients whose safety is at risk, and in implementing interventions to prevent falls and falls with injury."

Review of Patient #1's MR identified that on 1/20/2024, Patient #1 presented to the ED after a fall at home. Patient #1 was evaluated and discharged home on 1/21/2024 at 6:53AM. Five (5) hours and 20 minutes after ED discharge, on 1/21/2024 at 12:13PM, Patient #1 returned to the ED after a second fall at home and sustaining a dislocated finger. Patient #1 was evaluated, and a Computed Tomography Scan of the Head (CTH) resulted negative. Patient #1 was admitted to the hospital for falls at 4:01PM.

On 1/22/2024 at 8:11AM, while still in the ED awaiting an inpatient bed, Patient #1 sustained an unwitnessed fall. A Computed Tomography Scan of the Head (CTH) performed at 9:23AM revealed a significant intracranial bleed (brain bleed) and Patient #1 was brought to the operating room (OR) at 10:28AM for a Craniotomy (an operation to open the skull to access the brain for surgical repair). Patient #1 never regained consciousness and was removed from life support on 1/24/2024 at 5:56 PM.

Patient #1's MR lacked documented evidence that the required ED Kinder 1 Fall Risk Assessment was completed when Patient #1 returned to the ED on 1/21/2024 at 12:13PM. The MR also lacked documented evidence that a fall risk assessment was completed after Patient #1 was admitted on 1/21/2024 at 4:01PM. There was no documented evidence that fall prevention interventions were implemented for Patient #1 prior to their sustained fall in the ED on 1/22/2024 at 8:11AM.

The same lack of ED Kinder Fall Risk Assessments was identified in the MRs of Patient #s 3, 6, 7, 11, and 15.

Per interview of Staff C (Associate Director of Nursing Informatics) on 2/15/2024 at 10:41AM, Staff C confirmed these findings and stated that the Kinder Fall Risk Assessment should be performed on every patient presenting to the ED.

During interview of Staff B (Vice President/VP of Regulatory and Quality) on 2/15/2024 at 11:15AM, Staff B acknowledged these findings.

An Immediate Jeopardy (IJ) situation was identified on 2/16/2024 at 11:45AM for the facility's failure to assess patients for fall risk. The facility's failure to assess, identify, and implement preventative fall measures for at-risk patients resulted in a serious adverse outcome for Patient #1.

The facility provided an IJ Removal Plan to survey staff on 2/16/2024 at 3:13PM. The plan stated the following:

Beginning 2/16/2024, all nursing staff facility wide and currently working, and all nursing staff prior to the start of their shift, would be re-educated on the following:

- All Emergency Department RNs would be educated on the "Nursing Management of Fall and Injury Reduction in the Adult Patient in the Emergency Department" policy, to include emphasis on identifying, assessing, implementing, and documenting protective measures for patients at risk for falls in the ED.

- All Medical-Surgical and Critical Care RNs would be in-serviced on the "Fall Prevention and Injury Reduction in the Inpatient Adult" policy, to include emphasis on identifying, assessing, implementing, and documenting protective measures for inpatients at risk for falls.

- All RNs would be in-serviced on the "Post Fall Event Management" policy, to include a post fall huddle completion and occurrence event reporting completion.

The re-education would be delivered by Nurse Managers and Educators, and re-education progress monitored/tracked by the Director of Nursing Quality.

In addition, all occurrence reporting and initial investigations would be conducted and documented within 48 hours of the event, and a monthly Fall Event Report would be reported to the hospital Quality Assurance Performance Improvement (QAPI) committee.

The IJ was removed on 2/20/2024 at 2:00PM, based on the onsite verification of the IJ Removal Plan which included:

(a) Interviews conducted on 2/20/2024 with senior leadership, and review of education documentation and staff work schedules, confirmed that facility staff not yet in-serviced were not permitted to return to work until the in-service education was completed.

(b) Review of in-service Attendance Records/Attestations verified the number of staff captured/re-educated.

(c) Observations and interviews of staff in the patient care units, including the ED verified staff's knowledge/re-education of the Fall Risk policies.

(d) Review of medical records verified completion of the Kinder Fall Risk Assessments for ED patients, and the Morse Fall Risk Assessments for Inpatients.

As of 2:00 PM on 2/20/2024, 100% of nursing staff that worked since the IJ was identified on 2/16/2024 had completed their re-education training. A hospital-wide total of 91.2% of nursing staff had completed the re-education.

Based on medical record (MR) review, document review, and interview, in 1 (one) of 3 (three) MRs, nursing staff did not perform a post-fall event note, as per facility policy.

This lapse in post fall documentation potentially placed patients at risk for subsequent falls.

Findings:

The facility policy and procedure (P&P) titled, "Post Fall Event Management," last revised 01/2023, directed nursing staff to document a post-fall assessment/event note in the electronic health record (EHR) after a patient fall.

A SafetyNet (an incident reporting system application used to report adverse events/occurrences) Incident Report, dated 12/2/2023 at 3:40PM, identified Patient #5 had sustained an unwitnessed fall on 12/2/2023 at 2:30PM.

Review of Patient #5's MR identified no documented evidence of a post-fall event note, as per facility policy. In addition, there was no documented evidence that Patient #5 sustained a fall and was evaluated/treated after the fall event.

During interview of Staff E (Informatics Registered Nurse/RN) on 02/15/2024 at 10:43AM, Staff E confirmed these findings. Staff E stated that they also reviewed Patient #5's MR and could not locate any post fall event notes.

Based on medical record (MR) review, document review, and interview, nursing staff failed to: (A) Investigate fall occurrences as per facility policy, in two (2) of three (3) MRs; and (B) Update patients' plan of care after a fall event, in one (1) of three (3) MRs.

These failures potentially placed patients at risk for serious injury or harm.

Findings for (A):

The facility policy and procedure (P&P) titled, "Patient Safety Occurrence/Event Reporting," last reviewed 04/2023, directed nursing management to review safety occurrences and events for accuracy, change the status of the report to "Being Reviewed," and complete the manager review section within 14 days.

A SafetyNet (an incident reporting system application used to report adverse events/occurrences) Incident Report, dated 11/30/2023 at 2:01PM, identified Patient #4 sustained an unwitnessed fall on 11/30/2023 at 1:17PM. The manager review section of the report was not completed. In addition, the event was reviewed 11 (eleven) weeks after the incident report was filed, and was incomplete.

A SafetyNet Incident Report, dated 12/2/2023 at 3:40PM, identified Patient #5 sustained an unwitnessed fall on 12/2/2023 at 2:30PM. The manager review section of the report was not completed. In addition, the event was reviewed 10 (ten) weeks after the incident report was filed, and was incomplete.

During interview of Staff B (Vice President/VP of Regulatory and Quality) on 2/15/2024 at 2:54PM, Staff B confirmed these findings.

Findings for (B):

The facility P&P titled, "Post Fall Event Management," last reviewed 01/2023, directed nursing staff to update patients' Plans of Care after a fall.

Review of Patient #4's MR identified that Patient #4 had an unwitnessed fall on 11/30/2023. There was no documented evidence that Patient #4's plan of care was updated after the fall event.

During interview of Staff B (VP of Regulatory and Quality) on 2/15/2024 at 9:50AM, Staff B confirmed these findings.