HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 2 (Pt #1, Pt #11), clinical records reviewed for falls in the outpatient setting, the hospital failed to ensure that a nursing assessment; post fall documentation; or actions plans were implemented following fall events.

Findings include:

1. The hospital's policy titled, "Adult Patient Falls-Prevention and Intervention" (dated 10/23/2024) was reviewed and required, " ...Fall-Related Injury Level: The fall-related injury level is assessed at the time of the fall when the extent of the injury may not yet be known ...Minor[injury]: Resulted in ...pain, bruise, or abrasion, subgalea hematoma [localized blood clot due to trauma] ...Physiological Falls: A fall attributable to one or more intrinsic, physiological not urgent factors. Physiological falls include: Falls caused by a sudden physiological event such hypotension ...Unobserved fall: Include any case when a staff member finds the patient on the floor or other surface or when a fall is reported by the patient, a family member, or visitor ...Teammates will complete a patient safety event report after each patient fall event or near miss. Teammates will complete an injury report if indicated."

-Attachment D: MW Region Adult Outpatient/HOD & Emergency Department Procedure: Attachment to the Midwest Region Adult Patient Falls-Prevention and Intervention (dated 10/18/24), was reviewed required, " ... Teammates will monitor and support safety to prevent accidental and unpredictable falling by: Implementing environmental safety precautions ...Instruct patient about the extent to which they can get up with/without assistance. Provide patients with call light or mechanism ...Monitoring patients for changes in physiologic status that may increase risk for unpredicted falling ...Post-Fall Assessment/Care: Implement appropriate emergency response based on setting until relieved by responding teammates or emergency personnel. Monitor and document post fall assessment per patient presentation/condition."

2. The clinical record for Pt #1 was reviewed on 3/12/2025. Pt #1 presented to the hospital's Outpatient Pain Clinic on 7/1/2024 for an epidural steroid pain injection. Pt #1 was transferred to the hospital's ED (emergency department) following the procedure, for evaluation. Pt #1 discharged home from the ED on 7/1/2024.

Pt #1 arrived at the Medical Office Center (Outpatient Pain Clinic) on 7/1/2024 at 8:06 AM for an epidural steroid injection.
- The Interventional Procedure note (dated 7/1/2024), documented by the Anesthesiologist (MD #1), included, "Procedure: Therapeutic & Diagnostic Injection, Lumbar [back] epidural steroid injection ...Sign out: Final Procedure performed as above. Complications: Once loss was achieved and contrast confirmed location the patient endorsed feeling nauseous. HR (heart rate) was low 50's [normal range 60-100], down from [Pt #1] 70's. The steroid was injected and the patient was flipped on [Pt #1's] back and [Pt #1's] legs were raised. The patient's BP (blood pressure) remained stable and reported improvement. The patient was then monitored on [Pt #1's] back 15 minutes with normal HR and BP. Patient endorsed that [Pt #1] had resolution of [Pt #1's] symptoms. Patient sat up at the edge of the bed without difficulty. [Pt #1] was provided water. Soon after the patient had second episode of feeling nauseous and fell to the ground. [Pt #1's] right frontal region did impact the floor. The patient was assessed and was neuro (neurologically) intact ...The ER (emergency room) was notified and both me [MD #1] and the Registered Nurse [RN/E #2] transported to the ER ...Report was given to the triage nurse and the patient was transferred to the ER care time ..."

- Pt #1's nursing documentation from the Outpatient Pain Clinic RN (E #2), dated 7/1/2024, was reviewed. The clinical record included 2 sets of Pt #1's vital signs on the flowsheet (at 8:35 AM and 8:58 AM), from the registered nurse. The clinical record lacked any further nursing documentation or assessments, including a post-fall assessment or a post-fall huddle form.

- Pt #1 arrived at the ED on 7/1/2024 at 9:54 AM.

- The ED triage note (dated 7/1/2024 at 10:03 AM), included, "Chief complaint. Syncope (Syncopal) post procedure [fainting], hit [Pt #1] head, brought in from pain control clinic, receiving fluids prior to arrival, hit right side of head post procedure ..."

- The ED Provider note (dated 7/1/2024 at 11:01 AM), included, "presents [to] ED today for evaluation after 2 syncopal episodes at the pain clinic with fall after second episode... At this time, will plan for CT [computerized tomography/imaging] head given hematoma [blood clot under skin due to trauma] to right head as well as fall to the ground with [Pt #1] head being strike ...Will assess patient for potential underlying causes of [Pt #1] syncope ...Patient presentation may also be secondary due to vasovagal syncope due to [Pt #1's] first day of pain clinic injections. Will anticipate likely discharge home pending reassuring ED workup ..."

- The ED Provider note, (dated 7/1/2024) indicated that Pt #1 was discharged home on 7/1/2024 at 12:42 PM.

- Pt #1 sustained an injury on 7/1/2024, due to a fall. Pt #1's clinical record lacked a nursing post-fall risk assessment, completion of the post fall-huddle form or any interventions or actions plans implemented to prevent future falls.

3. A Patient Safety Event Form for Pt #1 (dated 7/1/2024 at 2:41 PM), was reviewed. The event summary included a detailed account of Pt #1's fall event on 7/1/2024. The event summary included follow-up documentation regarding Pt #1's grievance about billing. However, the event summary lacked any investigation, follow-up actions or discussion related to the fall on 7/1/2024. The hospital was unable to provide any investigation or education regarding Pt #1's fall, to date (3/13/2025).

4. The clinical record for Pt #11 was reviewed on 3/13/2025. Pt #11 presented to the Outpatient Pain Clinic on 10/29/2024 for a pain management procedure.

- Pt #11 had a fall event on 10/29/2024. Pt #11 had an assisted fall to the floor. Pt #11 discharged home from the Outpatient Clinic on 10/29/2024. There were no documented injuries. Pt #11's clinical record lacked a nursing post-fall risk assessment, completion of the post fall-huddle form or any interventions or actions plans implemented to prevent future falls.

5. On 3/12/2025 at 2:08 PM, a phone interview was conducted with the Outpatient Pain Clinic RN (E #2). E #2 stated that Pt #1 came in for a pain procedure. E #2 stated that Pt #1 fainted after the procedure and was laid back on the table. E #2 stated that after Pt #1 recovered, Pt #1 sat up on the table for 5 minutes. E #2 stated that while Pt #1 was sitting on the table, another patient came in. E #2 stated that E #2 left Pt #1's room. E #2 stated that when E #2 was out of Pt #1's room, E #2 heard a loud thump. E #2 stated that E #2 went back into Pt #1's room and saw that the patient was on the floor. E #2 stated that Pt #1 was assisted into a wheelchair and was then transported over to the ED. E #2 stated that the only discussion following, Pt #1's fall, was with E #5 (Unit Manager), in which E #2 complained about the need of another nurse. E #2 stated that E #2 also voiced the concern of needing call lights in the patient rooms. E #2 stated that since July 2024 to current, there have not been any call lights installed in the patient rooms. E #2 stated that there has not been any education or in services post Pt #1's fall event. E #2 reviewed Pt #1's clinical record and confirmed that a nursing note/assessment was not documented following Pt #1's fall.

6. On 3/13/2025 at 10:18 AM, an interview was conducted with the Chief Nursing Officer (E #1). E #1 stated that E #1 provides oversight to both inpatient and outpatient nursing areas. E #1 stated that in regard to outpatient clinical areas, fall prevention would include assessment of the patient's diagnosis and history. E #1 stated that if a patient had a history of falls or syncope, then extra precaution will be taken with assisting patients entering and exiting the exam room. E#1 stated that if a patient had a syncope event, additional monitoring should take place. E #1 stated that if a patient falls, the first step would be to assess the patient for injuries. E #1 stated that the expectation from the nurses following a fall, would include the nurse documenting an assessment and if there was harm/injury to the patient. E #1 stated that a safety event/incident form should be documented and there should be follow-up and an action plan implemented on that safety event form. E #1 acknowledged that Pt #1's safety event form (7/1/2024), lacked follow-up investigation related to the fall.