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A. Based on document review and interview, it was determined that for 1 of 4 (Pt.#1) clinical records reviewed for fall risk assessements and precautions, the hospital failed to ensure that the registered nurse appropriately assessed or re-evaluate the patients' for fall risk and implement additional fall precautions.

Findings include:

1. The hospital's policy titled, "Fall Precautions Procedure" (revised 10/14/24) was reviewed and included, "This procedure applies to all Nursing Staff withing the Inpatient Care Units ... ED ... Universal Precautions are fundamental patient safety standards will be applied to all patients, these include, Bed low and locked, purposeful rounding, call within reach, side rails up x2 ... The Nurse will assess and/or review fall risk and document interventions at the following times: A. Within four (4) hours of arrival ... Change in patient condition or level of care ... As stated above, all (low risk) patients will have Universal Fall Precautions in place."

2. The clinical record for Pt.#1 was reviewed on 04/11/25. Pt.#1 presented to the Emergency Department (ED) on 12/19/24 at 2:18 PM, with a chief complaint of fatigue and dizziness. The clinical record included the following:

-ED Triage Note, dated 12/19/24 at 2:30 PM, "To ED from home with complaint of feeling tired and dizzy for the past day ... is diaphoretic and lethargic in triage. Unable to get BP (blood pressure) or temperature despite multiple attempts. (Pt.#1) taken straight to main Ed."

-ED Notes dated 12/20/24 at 12:21 AM, "(Pt.#2) getting out of bed multiple times. Attempts to reorient back to reality unsuccessful. Refusing all medical help ... Requested possible medication from MD. MD stated waiting for daughter's arrival before re-evaluating."

-Fall Risk Assessments during 12/19/24 at 2:45 PM to 12/20/24 at 2:00 PM were reviewed. The fall risk score on 12/19/24 at 4:00 PM was stratified as Low Risk, there was no documentation of fall precautions implemented. The flowsheets did not include a fall risk re-assessment after (Pt.#1) showed change in mental status during this time.

3. An interview with an ED Registered Nurse (E#2) was conducted on 04/11/25 2:06 PM. E#2 stated that all patients are assessed for fall risk and depending on their score fall precautions are implemented. Patients presenting with dizziness or fatigue would not be considered a low risk for falls and precautions should be implemented. If there is a change in the patient's condition they are reassessed, and the physician should be notified.

B. Based on document review and interview, it was determined that for 1 of 4 (Pt.#1) clinical records reviewed for patients that required immediate labs, the hospital failed to ensure that a registered nurse completed physician's orders, as required.

Findings include:

1. The hospital's policy titled, "Emergency Department (Scope of Care) Nursing Practice" (revised 10/5/24) was reviewed and required, " ... 2. Initiate appropriate pre-established protocol when patient conditions warrant upon arrival to treatment area ... 3. Establish intravenous access and maintain as ordered by ED physician ... 4. RN will notify and collaborate with physician and ancillary departments for interventions based on ... patient care assessments."

2. The clinical record for Pt.#1 was reviewed on 04/11/25. Pt.#1 presented to the Emergency Department (ED) on 12/19/24 at 2:18 PM, with a chief complaint of fatigue and dizziness. The clinical record included the following:
-Physician Order, dated 12/19/24 at 5:41 PM, "Venous Arterial Gas (once) Immediate."

-Venous Blood Gas Results, dated 12/19/24 at 8:23 PM, "PH Venous 7.30 low (reference range 7.32-7.43/used to measure acidity or basicity); PC02 52.2 high (41.0-51.0/partial pressure of carbon dioxide-measures amount of C02 in blood); P02 Venous 25.3 L (30.0 - 40.0/partial pressure of oxygen-measures amount of 02 in blood); 02CT 9.1 L (15.0-22.0/oxygen content-amount of 02 in blood); 02 Sat Venous 38.8 (94.0 - 99.0)." The lab results indicated that the specimen was collected by the RN (E #11) at 8:08 PM (2 hours and 27 minutes) after the order was placed.

3. An interview was conducted with an Advanced Practice Nurse (E#1) on 04/11/25 at 1:40 PM. E#1 stated that labs that are ordered as "Immediate" should be drawn right away.