HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure patient safety when a patient fall resulted in serious injury/death.

Findings:

On April 28, 2010 at 3:10 PM, an unannounced visit was made to Tulare Regional Medical Center following an entity-reported incident of Patient X suffering a fall in the Emergency Room (ER).

During an interview with the Compliance Officer on April 28, 2010 at 3:25 PM, she stated she was aware of the fall that occurred on April 15, 2010 at 9:15 AM. Patient X was on the emergency room gurney while waiting for an inpatient bed. The patient fell from the gurney and sustained a serious injury to her head as indicated by the CT scan (computed tomography X-ray). Initially, Patient X was transferred to another hospital for higher level of care. The neurosurgery consult determined Patient X was not a surgery candidate, and patient was returned back to the original hospital at the family ' s request on April 15, 2010. Patient X was made DNR (Do Not Resuscitate) on April 16, 2010 for poor prognosis, and patient died on April 17, 2010.

The ER was observed on April 28, 2010 at 3:55 PM with the Compliance Officer. ER gurneys had two full-length side rails that lowered below the height of the gurney mattress.

On April 29, 2010, the Emergency Department Record (EDR) was reviewed. EDR, page 2 of 3, dated April 15, 2010 under Medication Administration indicated Patient X received Inderal (Medication to treat high blood pressure) 30 mg Intra Venous (IV - into the vein) at 5:52 AM and Morphine (Narcotic pain medication) 2 mg IV at 5:52 AM and 6:40 AM. Under Additional Notes, 8:00 AM entry indicated, "Pt (Patient) requesting food. ADA (American Diabetic Association) diet tray ordered." The 9:09 AM entry indicated, "ADA tray provided." The 9:16 AM entry indicated, "Pt found on floor face down c/o (complaint of) head pain."

CT scan report dated April 15, 2010 indicated, "large area of intraparenchymal bleed (Bleeding into the brain) ... There is approximately 13 mm of leftward midline shift (about half inch movement of brain matter to the left) ... Intraventricular hemorrhage (Bleeding into spaces in the brain containing cerebral spinal fluid) is present in both lateral ventricles, third and fourth ventricles." Emergency Room Report dated April 15, 2010 by ER Doctor stated, "I received a call from Radiology stating that the patient had a large right-sided intracranial (inside the head) hemorrhage (bleeding) ... There was a significant amount of midline shift (movement of brain matter) ... " Record of Death dated April 17, 2010 indicated time of death at 5:08 PM.

LVN 1 was interviewed on April 29, 2010 at 1:45 PM. She stated she was assigned to Patient X on the day of the incident. While waiting to be admitted to the inpatient area of the hospital, Patient X told LVN 1 she was hungry. LVN 1 ordered a breakfast tray for Patient X. When the breakfast tray arrived LVN 1 set the breakfast tray on the procedure stand (Mayo table, small tray table that hangs over the patient) and raised the head of the gurney. Both side rails were up. LVN 1 lowered the left side of the rail (left side to Patient X). She then moved the breakfast tray close to Patient X. LVN 1 then went to the nurses ' station to chart when she heard the noise of tray and plates falling a few minutes later. When she ran to Patient X, she was found on the floor face down. Patient X told LVN 1, " I fell and hurt my head."

On April 29, 2010 at 1:35 PM when the Compliance Officer was asked what policy and procedures were in place that addressed feeding patients in the ER, she stated, "We do not have the policy change in place at this time, but as of yesterday, we decided to use lap trays with both gurney side rails up for feeding."