HospitalInspections.org

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Based on interview, record review and observation the facility failed to ensure the safety of 1 Patient (Patient #10) admitted to the Emergency Department (ED). Specifically, the facility failed to conduct post fall assessments for 1 patient (out of 8 sampled patients with falls). This failed practice placed patients at risk for less than optimal health outcomes. Findings:

During a telephonic interview on 11/20/18 at 2:30 pm with Patient #10, he/she stated he/she had fallen in the ED at "Regional Hospital". Specifically, Patient #10 stated he/she was walking from the exam room to the bathroom and fell to the floor.

Record review on 1/16-18/19 of Patient #10's medical record revealed no evidence of a fall; post fall assessment or follow-up during his/her stay at the facility's ED.

Observation on 1/17/19 of the facility's security video dated 10/11/18 at 2:00 pm, from the ED, revealed Patient #10 ambulating towards a bathroom from his/her room unassisted and fell to the floor.

Interviews on 1/17/19 at 3:15 pm, with the Director of Patient Safety & Risk Management and the Director of Emergency Services confirmed Patient #10 fell in the ED on 10/11/18 at 2:00 pm.

Further interviews with the Director of Patient Safety & Risk Management and the Director of Emergency Services confirmed there was no documentation in the patient's record indicating a fall on 10/11/18. When asked if staff should have documented the fall and provided follow up care, both confirmed documentation should have been in Patient #10's Electronic Medical Record.

During an interview with ED Physician #1 on 1/18/19 at 11:20 am, he/she stated the expectation after a patient's fall would be the physician re-evaluated the patient and documented the findings. In addition, he/she stated the fall, re-evaluation and follow up should have been documented in both the physician notes and the nurses' notes. He/she also stated it is the expectation to document an "addendum" to the patient's chart if the physician didn't document during the ED visit.

Review of the facility policy number HOSP.902.560 effective date 8/2018, titled "Fall Prevention Program" revealed the following:

"OUTPATIENT - EMERGENCY DEPARTMENT
1. In the Emergency Department, all patients are considered to be at risk for falling. Additional fall precautions are implemented per nursing judgement and patient assessment.
2. If a patient falls, a post-fall assessment, including vital signs and provided notification must be documented.
3. If a patient falls, a detailed nursing note must be entered in the patient record including, the date and time of fall, description of the fall, results of the post-fall assessment and any notifications that have occurred.
4. If a patient falls, include risk for injury into the patient care plan.
5. If a patient falls, add 'fall during hospital admission' into Admission History. This will show on the patient's history for future admissions.
6. If a patient falls, complete an occurrence report and the post-fall debrief form. Return to manager or house supervisor."
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Based on record review, observation and interview the facility failed to ensure medical records were completed for 1 Patient (Patient #10), out of 20 sampled patients, whose records were reviewed. Specifically, the facility failed to document in Patient #10's record a fall experienced in the facility Emergency Department (ED) and any follow up assessments or care related to the fall. This failure had the potential to negatively impact the patients' future medical care. Findings:

Record review on 1/16-18/19 of the patient's medical record revealed no evidence or documentation of a fall on 10/11/2018 while seeking care as an outpatient in the facility ED.

Observation on 1/17/19 of the facility's security video dated 10/11/18 from the ED revealed Patient #10 ambulating in the hall unassisted and falling to the floor.

Interviews on 1/16-18/19 with the Director of Emergency Services and the Director of Patient Safety & Risk Management confirmed no documentation in the patient's record indicating a fall on 10/11/18. When asked if staff should have documented the fall and any follow up care, both confirmed documentation should have been in the patient's chart.

During an interview with ED Physician #1 on 1/18/19 at 11:20 am, he/she stated the expectation after a patient's fall would be for the physician to re-evaluate the patient and document the findings. In addition, he/she stated the fall, re-evaluation and follow up should be documented in both the physician notes and the nurses' notes. He/she also stated it is the expectation to document an "addendum" to the patient's chart if the physician didn't document during the ED visit.

Review of the facility policy number ED.103.003, effective date 6/2016, titled "Medical Record, Emergency Department" revealed under section 4; "Each time a patient visits the Emergency Department, the following information is entered in the patient's medical record: subpart C; clinical observations, including response to treatment and medication effects".

Review of the facility policy number HOSP.902.560 effective date 8/2018, titled "Fall Prevention Program" revealed the following:
"OUTPATIENT - EMERGENCY DEPARTMENT
1. In the Emergency Department, all patients are considered to be at risk for falling. Additional fall precautions are implemented per nursing judgement and patient assessment.
2. If a patient falls, a post-fall assessment, including vital signs and provided notification must be documented.
3. If a patient falls, a detailed nursing note must be entered in the patient record including, the date and time of fall, description of the fall, results of the post-fall assessment and any notifications that have occurred.
4. If a patient falls, include risk for injury into the patient care plan.
5. If a patient falls, add 'fall during hospital admission' into Admission History. This will show on the patient's history for future admissions.
6. If a patient falls, complete an occurrence report and the post-fall debrief form. Return to manager or house supervisor."

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