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YAVAPAI REGIONAL MEDICAL CENTER 1003 WILLOW CREEK ROAD PRESCOTT, AZ 86301 Jan. 31, 2017
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on review of hospital policy, documents, medical record, staff and physician interviews, it was determined that the hospital failed to require the hospital's internal investigation analyzed and identified that the staff did not notify the physician and nurse when 1 of 1 patient fell in Radiology and sustained a fractured leg (Patient #6). This deficient practice resulted in the delay of treatment for the injury.

Findings include:

The hospital policy titled Risk Management Reports (last approved 08/28/2015) requires, "...Incidents include...falls...Any patient Risk Event resulting in severe patient injury should be reported to the Supervisor/Director; Nursing Supervisor: Administrator on Call, and Quality/Risk Management...Risk Events should be reported within 24 hours of the incident occurrence by the employee with the most knowledge of the incident...facts of the incident and follow up care will be recorded in the patient's medical record...Physician(s) will be notified within 12 hours of an incidence occurrence if the patient incident warrants. Documentation of physician contact will be included in the patient medical record when documenting the event...The following indicate the expected follow-up response time by the investigating Department Director/Designee...Seven (7) days from the date the event has been entered (into the hospital's computerized complaint system)...All Risk Events should be closed with investigation completed within thirty (30) days of initial entry...Thorough documentation of the investigation should be included with each Risk Event...documentation should address why the event occurred...and what actions are being taken to prevent it from happening again...."

Patient #6 presented to the Emergency Department (ED) with vomiting on 11/27/16. The ED physician ordered pre-surgical chest X-rays for an abdominal procedure. While standing for the X-ray in Radiology, and attended by X-ray Technician #14, the patient fell to the floor. Post fall, X-Ray Technician #14 returned the patient to the ED without documenting or notifying the ED nurse, ED Charge Nurse, ED Physician Assistant, or ED physician. Four (4) days later the patient informed the attending physician of the fall who then ordered X-Rays of the extremity that confirmed a fracture. The physician then ordered a leg immobilizer and the patient was subsequently discharged to an inpatient rehabilitation facility.

X-Ray Technician #14 initially reported the fall on hospital documents (occurrence report) however misidentified the patient. The hospital confirmed the error on 12/13/16 after which the hospital conducted the internal investigation for the correct patient and erroneously concluded, based on their interview with X-Ray Technician #14 that Patient's #6 physician and nurse were notified of the fall on 11/27/16.

The ED physician, ED RN, ED Charge Nurse, and ED Physician Assistant (all identified in the medical record as providing care to Patient #6 on 11/27/16) confirmed during interviews conducted 01/23/17 to 01/27/17, that they were not notified of Patient #6's fall in Radiology that occurred on 11/27/16. The surveyor attempted to interview X-Ray Technician #14 during a teleconference on 01/23/17 however s/he was not forthcoming with information.

The hospital's Risk Management failed to identify that the staff did not follow through as required by hospital policy, thus delaying the patient's care/treatment for Patient's #6 fractured leg injury.