The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


A. Based on document review and interview, it was determined that for 3 of 4 (Pt #1, Pt #2, and Pt #7) clinical records reviewed for patients seen in the Hospital's Emergency Department (ED), the Hospital failed to ensure the completion of a Fall Risk Assessment on patients on arrival to the ED.

Findings include:

1. The Hospital's policy titled, "Fall Risk Assessment/Fall Prevention Program" (revised 08/2017) was reviewed on 7/16/18 at approximately 2:00 PM and required, " ...Upon admission/or transfer, or change in condition, and after a fall has occurred, adult patients (includes inpatient and outpatient) should be assessed for risk for falls ..."

2. Pt #1's clinical record was reviewed on 7/16/18 at approximately 10:00 AM. Pt #1 was a [AGE] year old female, admitted on [DATE] with a diagnosis of agitation. Pt #1's clinical record lacked documentation of a Fall Risk Assessment.

3. On 7/17/18 at 9:35 AM, Pt. #7's medical record was reviewed. Pt. #7 was a [AGE] year old female, admitted to the Emergency Department (ED) on 1/23/18 for a urinary tract infection. Pt. #7's initial nursing assessment did not include a Fall Risk Assessment on arrival to the ED. Pt. #7's ED documentation, dated 1/23/18 at 3:44 PM, included, "Pt. [Pt. #7] stated that she fell off of [the] bed at about 3:15 PM apparent injury noted ..."

4. The clinical record for Pt #2 was reviewed on 7/16/18 at approximately 10:15 AM. Pt #2 was a [AGE] year old male who presented to the Hospital's Emergency Department (ED) on 3/30/18 at 7:21 AM with complaints of lower back pain and swelling to spine. The nurse's (E #8) initial assessment of Pt #2 did not include a fall risk assessment. E #8's note, dated and timed 3/30/18 at 2:32 PM, included, "Pt found on ground in room. Stated that he fell asleep and fell out of bed and hit head. Fall was unwitnessed. Alert and acting at baseline." Pt #2's Fall Risk Assessment by E #8, completed on 3/30/18 at 2:37 PM (after Pt #2's fall), indicated a Morse Fall Risk Score of 50 (High Fall Risk), and the fall precautions indicated for Pt #2, based on this score, included the call light within reach and side rails up for support. These precautions were not put into place until after Pt #2's fall.

5. During an interview with the Director of Risk Management (E #6), on 7/17/18 at approximately 10:45 AM, E #6 stated that a fall risk assessment should be completed on every patient on arrival to the ED.

B. Based on document review, observation and interview it was determined that for 1 of 4 patients (Pt. #5) reviewed for falls, the Hospital failed to ensure that fall safety precautions were implemented.

Findings Include:

1. On 7/16/18 the Hospital's policy titled, "Fall Risk assessment/Fall Prevention Program" (revised 8/17) was reviewed. The policy required, "2. Interventions for patients with Morse scale equal to or higher than 45 ...patient may need shoes rather than slippers for no-skid footwear and support ...Once the patients identified as a high risk, a visible fall risk identifier will be placed on the patient."

2. On 7/16/18, Pt. #5's medical record was reviewed. Pt. #5 is a [AGE] year old female admitted for hypotension on 7/10/18. Pt. #5's Fall Risk Assessment, completed on 7/16/18 at 1:16 AM, indicated a Morse (fall risk model) Fall Risk score of 50 (High Fall Risk).

3. On 7/16/18 at approximately 11:20 AM, an observational tour was conducted of the telemetry/stroke unit. A safety risk sign was observed on the door of Pt #5's room. Pt. #5 was observed resting in bed without a safety risk armband or no-skid socks in place.

4. On 7/16/18 at approximately 11:25 AM, an interview was conducted with the telemetry/stroke unit Charge Nurse (E #3). E #3 stated that Pt. #5 should have the yellow safety arm band and no-skid socks in place, due to fall risk. E #3 stated that yellow arm bands, yellow no-skid socks and bed alarms are interventions for the fall risk protocol.