HospitalInspections.org

Based on medical record review and document review, in one (1) of three (3) medical records reviewed, the facility did not ensure that patients who are identified at risk for fall, receive timely intervention and observation, as per facility policy. (Patient #10)

Findings include:

Review of Medical Record for Patient #10 revealed: this 71-year-old male patient, with a history of hypertension, was brought by ambulance to the hospital emergency department (ED) on 2/16/19 at 7:15 PM, with complaint that he tripped and fell.

He was assessed at triage to be at risk for fall. A yellow risk band was placed on his hand and ED alerts field were updated to reflect fall risk. Patient was assigned triage priority ESI-2 (High Risk Situation). After triage, patient was sent to fast track waiting area.

An Occurrence Report form dated 2/16/19, noted a fall occurrence at 9:55 PM and described the following: Patient seen on floor, family members stated patient was going to the bathroom and had a seizure. Patient sustained laceration to left eyebrow. Patient awake and responsive to all stimuli. Patient placed on stretcher and taken to Critical Care Trauma. Patient was seen and evaluated by the physician, CT-scan of the head and laboratory test were ordered and laceration repaired.

The facility policy and procedure titled "Triage of Emergency Department Patients,"
last revised May 2, 2018, stated the following: "Triage levels and assignment ESI-2, High Risk Situation: when this condition is identified, the patient is taken to the appropriate area (CCT or Main) for intervention and physician evaluation within 30 minutes."


The facility policy and procedure titled "Falls Prevention and Management,"
last revised April 10, 2018, stated the following: "Emergency Department, Patients identified at risk for fall will have a yellow ID band placed on their wrist. Staff will implement standard fall precautions on all patients. Staff will document all observations and interventions in medical record/EMR."

The hospital did not ensure that this patient who was triaged level ESI-2 , and identified to be at risk for fall, was taken to the appropriate area and received timely interventions and observations.

Based on medical record review, document review and staff interview, in three (3) of three (3) medical records reviewed, the facility failed to document, analyze and track all fall incidents occurring in the Emergency Department (ED). (Patient #6, #7 and #8).


Findings include:

Review of the document titled "Emergency Department Daily 24 Hour Census," identified there were 3 (three) fall occurrences in the ED on 3/29/19. There were no documented fall occurrence reports.

During interview on 6/5/19 at 11:00 AM, Staff C, Director of Nursing ED, confirmed the finding and stated that the documentation of the falls were in the medical records of the patient, but occurrence reports could not be found.


Review of the Medical Record for Patient #6 revealed: patient is a 50-year-old male who was brought in by ambulance on 3/29/19 at 9:17 PM, after being found on the ground level of subway entrance. At triage on 3/29/19 at 9:10 PM, the nurse classified the patient as ESI-3 (requires two or more resources with vital signs not within the danger zone) and at no risk for fall.
At approximately 3:00 AM on 3/30/19 the patient was seen attempting to get out of the stretcher with 2 side rails up, Patient was assisted back to stretcher and was reassessed, the nurse documented that there was no signs of injury or trauma. On 3/30/19 at 12:51 PM, the physician documented the presence of a right comminuted displaced fracture of the distal radius extending from the metaphysis to the intra-articular joint.


Review of the Medical Record for Patient #7 revealed: The patient was brought in by ambulance on 3/29/19 and was triaged at 9:51 PM. The patient gave a complaint of alcohol ingestion. Patient was assessed as not at risk for fall. and was classified as ESI-3. At 11:04 PM, the nurse documented that the patient was found on the bathroom floor next to his assigned area. Patient was visibly intoxicated.

Review of the Medical Record for Patient #8 revealed: A 69 -year-old male patient presented to Emergency Department (ED) on 3/29/19 at 5:04 PM with complaint of black stool times three (3) weeks; history of hypertension, diabetes and alcohol abuse He was assessed at triage to be at risk for fall. Nursing noted on 3/30/19 at 2:00 AM that the patient got out of bed and fell to the floor, no new injury, denies pain at this time, physician aware, vitals are stable, Patient was placed back on stretcher, all safety protocol in place.

The ED staff failed to create occurrence reports for the falls. There was no documented evidence that the falls were included in the facility's falls data.

A review of the facility policy and procedure titled: "Falls Prevention and Management," effective March 2018, states: "Reporting: All patient falls will be reported to Risk Management, Quality Management and Falls Prevention Committee."

Based on document review and staff interview, in 2 (two) of 3 (three) medical records reviewed, it was determined: (a) staff in the Emergency Department (ED) did not appropriately assess patients risk for fall, and (b) staff did not re-evaluate the patient after a fall.

Findings include:

Review of the medical record for Patient #6 revealed: Patient is a 50 year old male brought by EMS (Emergency Medical Services) to the ED on 3/29/19 at 9:17 PM, after he was found at the bottom of the subway stairs. Patient reported to EMS that he fell about 2 steps and was intoxicated. At triage on 3/29/19 at 9:10 PM, the patient was classified as ESI-3 (requires two or more resources with vital signs not within the danger zone) and at no risk for fall.
On 3/30/19 at 3:00 AM, approximately 6-hours after triage, the patient was seen attempting to get out of the stretcher with 2 side rails up. Patient was assisted back to stretcher and was reassessed. The Nurse documented that there was no signs of injury or trauma.
On 3/30/19 at 12:51 PM, The physician documented the presence of a fracture of the right radius.


Review of the medical record for Patient #7 revealed: A 45-year-old male patient brought in by ambulance on 3/29/19 at 9:51 PM. The patient gave a complaint of alcohol ingestion and presented with unsteady gait. During triage at 9:51 PM the patient was assessed as not at risk for fall. At 11:04 PM, the nurse documented that the patient was found on the bathroom floor next to his assigned area and the patient was visibly intoxicated.


A review of the facility policy titled, "Falls Prevention and Management- Attachment 1A Modified Morse Fall Risk Scale (MMFS)," provided a scoring methodology for determining fall risk. The surveyor identified that the triage nurse failed to classify Patient #6 and #7 as being at risk for falls, as dictated by the risk factors and scoring methodology provided in the MMFS.

This finding was confirmed by Staff C, Director of Nursing ED, during interview on 6/5/19 at approximately 11:00 AM.


Review of the medical record for Patient #8 revealed: A 69 year old male patient presented to the ED on 3/29/19 at 5:04 PM with diagnosis including alcohol abuse and black stool for 3 weeks. The patient was triaged and identified as being at risk for fall on 3/29/19 at 5:04 PM. A yellow risk band was placed on the patient and ED alerts field were updated to reflect fall risk. The patient was initially evaluated by the physician at 6:54 PM on 3/29/19.
On 3/30/19 at 2:00AM, nursing documented that the patient got out of bed and fell. The nurse further stated that the physician was aware and vital signs were stable.

There was no documented evidence of re-examination of the patient by the physician after the fall.

The facility policy titled, "Falls Prevention and Management," states: In the event of a fall, the RN provides immediate care to the patient, facilitates provider post fall evaluation of patient and completes required investigation and documentation.