HospitalInspections.org

Based on observation, record review, and interview, the CAH failed to ensure the physical environment was maintained for the safety of patients. This deficient practice was evidenced by failing to ensure the ED consult room used for patient care had a call bell system for patients' to contact hospital staff. This deficient practice had the potential to impact ED patients' placed in the ED consult room.
Findings:

Observation of the emergency department on 06/12/2025 at 8:37 AM revealed the ED consult room did not have a call bell system for patients' to contact hospital staff.

Review of Patient #1's medical record revealed, in part, Patient #1 arrived in the ED on 05/12/2025 at 4:07 PM with a chief complaint of hand injury. At 4:17 PM, Patient #1 had a pain assessment pain rating of 8 on a scale of 0-10 (0-no pain, 10-worst possible pain). At 5:19 PM, Patient #1 transferred to ED consult room. At 5:27 PM, Patient #1 had an IM injection of Ketorolac 30 mg (used for treatment of moderate to severe pain). At 5:42, Patient #1 "was yelling for a nurse. RN walked in on patient sitting in the chair. Patient stated that they fell out of the chair onto the floor and hit their left hip. Patient diaphoretic upon assessment." Further review of Patient #1's medical record revealed, in part: "Post Fall Summary: Safety Interventions at time of fall: Instructed to call staff for mobility."

In an interview on 06/12/2025 at 8:41 AM, S2ED Manager confirmed the ED consult room did not have a call bell system and Patient #1 could not call staff. S2ED Manager confirmed the hospital ED consult room used routinely or daily for patient care, such as, medication administration, venipuncture for laboratory work, IV cannulation, and discharge instructions.

Based on record review, observation, and interview, the CAH failed to ensure emergency department nursing services were provided to meet the needs of the patient. This deficient practice was evidenced by failing to ensure nursing staff monitored a patient that experienced a potential adverse medication reaction after an IM injection for 1 (#1) of 3 (#1-#3) sampled patients.
Findings:

Review of the hospital "Quick Sheet" for Intramuscular (IM) injections revealed, in part: "IM injections have been associated with adverse effects and pain, and this route of medication injection should be used as a last resort. 34. Stay with the patient for several minutes and observe for any allergic reactions. Dyspnea, wheezing, and circulatory collapse are signs of severe anaphylactic reaction. 36. Watch the patient for adverse and allergic reactions to the medication. If a reaction occurs, follow the organization's practice for emergency response. Report rash, seizures, and difficulty breathing."

Review of Patient #1's medical record revealed, in part, Patient #1 arrived in the ED on 05/12/2025 at 4:07 PM with a chief complaint of hand injury. At 4:17 PM, Patient #1 had a pain assessment pain rating of 8 on a scale of 0-10 (0-no pain, 10-worst possible pain). At 5:19 PM, Patient #1 transferred to ED consult room. At 5:27 PM, Patient #1 had an IM injection of Ketorolac 30 mg (used for treatment of moderate to severe pain). At 5:33 PM, Patient #1's vital signs were: BP: 127/65; Pulse: 88. At 5:40 PM, Patient #1's vital signs were: BP: 111/60; Pulse: 59! (Pulse decreased by 29 beats per minute from previous reading). At 5:42, Patient #1 "was yelling for a nurse. RN walked in on patient sitting in the chair. Patient stated that they fell out of the chair onto the floor and hit their left hip. Patient diaphoretic upon assessment."

Observation of the emergency department on 06/12/2025 at 8:37 AM revealed the ED consult room did not have a call bell system for patients' to contact hospital staff.

In an interview on 06/12/2025 at 8:41 AM, S2ED Manager confirmed the ED consult room did not have a call bell system and Patient #1 could not call staff.

In an interview on 06/12/2025 at 10:20 AM, S2ED Manager confirmed that it was nursing judgment for how long to monitor a patient after an IM injection and observe for adverse and allergic reactions to the medication.

Based on record review and interview, the CAH failed to ensure the emergency department registered nurse evaluated the nursing care for each patient. This deficient practice was evidenced by failing to ensure a registered nurse completed fall risk assessments for 2 (#1, #3) of 3 (#1-#3) sampled patients.
Findings:

Review of hospital policy "Emergency Department Assessment Standards" with an Approval Date: 10/27/2023 revealed, in part: "I. The purpose of this policy is to establish assessment guidelines for patients presenting to the Emergency Department (ED). III. All patients presenting to the ED will be appropriately assessed. IV. Policy Implementation. B. General Assessment: 1. The following will be reviewed and documented by the RN and/or paramedic on the medical record, if applicable: e. Fall risk."

1. Review of Patient #1's medical record revealed, in part, Patient #1 arrived in the ED on 05/12/2025 at 4:07 PM with a chief complaint of hand injury. At 5:19 PM, Patient #1 transferred to ED consult room. At 5:27 PM, Patient #1 had an IM injection of Ketorolac 30 mg (used for treatment of moderate to severe pain). At 5:42, Patient #1 "was yelling for a nurse. RN walked in on patient sitting in the chair. Patient stated that they fell out of the chair onto the floor and hit their left hip. Patient diaphoretic upon assessment." Further review of Patient #1's medical record revealed no evidence fall risk assessment completed prior to Patient #1 stating that they fell.

In an interview on 06/12/2025 at 10:22 AM, S2ED Manager confirmed Patient #1 did not have a fall risk assessment completed prior the patient stating that they fell.

2. Review of Patient #3's medical record revealed, in part, Patient #3 arrived in the ED on 06/07/2025 at 12:22 PM with a chief complaint of back pain. At 1:22 PM, Patient #3 had IM injections of Ketorolac 60 mg and Orphenadrine 60 mg (muscle relaxant). At 1:38 PM, Patient #3 discharged from the hospital. Further review of Patient #3's medical record revealed no evidence fall risk assessment completed.

In an interview on 06/12/2025 at 10:56 AM, S2ED Manager confirmed Patient #3 did not have a fall risk assessment completed.