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Based on interview and record review, the facility failed to ensure a safe setting for one vulnerable patient (Patient B), resulting in a fall.

Findings:

The facility report was reviewed on March 4, 2010. The report indicated that on January 27, 2010 Patient B visited the Emergency Department (ED) and was diagnosed with a stable fracture of the left thigh bone due to a fall at an assisted living facility. The report specified that because the fracture was stable, the patient could ambulate with her walker and was about to be discharged back to her assisted living facility. While preparing for discharge, the patient asked to use the restroom. The registered nurse (RN 1) waited outside the restroom door as the patient got up without asking for help. The patient fell. Although further x-rays did not reveal any additional damage to the fracture site, the patient was admitted and underwent surgery to repair the hip fracture.

During an interview on March 4, 2010 at 4:25 PM with the administrator of a skilled nursing facility (SNF) where Patient B currently resided, she stated the patient had periods of confusion.

During an interview with Patient B at the SNF on March 4, 2010 at 4:25 PM, she was asked if she remembered falling in the ED. The patient replied, "You mean tomorrow?...At my age and all my falls in the last two years, I'm not myself."

The clinical record for Patient B at the SNF was reviewed on March 4, 2010. Diagnoses included dementia, and the admission comprehensive assessment dated February 15, 2010 indicated the patient had some difficulty cognitively in new situations.

During an interview with the facility Chief Quality Officer (CQO) on March 4, 2010 at 2:35 PM, she stated RN 1 had instructed Patient B to call when she was finished in the restroom.

During an interview with family member (FM) 2 on March 11, 2010 at 2:18 PM, she stated a male nurse (RN 1) took Patient B to the restroom, and the patient asked for her privacy, but the nurse should have gotten someone to help Patient B. "I think probably (Patient B) wouldn't have minded me being in the restroom with her... (RN 1) wasn't right by the door...I thought he would have stayed by the door."

During an interview with family member (FM) 1 on March 11, 2010 at 2:54 PM, she stated that prior to the fall in the restroom, she saw that Patient B "started to stand up and she couldn't do what they wanted her to do, so the male nurse (RN 1) had to pick her up and put her back on the gurney...She couldn't stand up. She had come initially by ambulance. Somebody should have gone with her (into the rest room) based on the fact that she couldn't stand and had to be picked back up onto the gurney." FM 1 added that while Patient B was in the restroom, FM 1 had gone to get her car, but "The nurse could have asked (FM 2) to help...I don't think she would have minded (FM 2) helping her in the rest room."

During an interview with RN 1 on March 4, 2010 at 2:45 PM, he stated that he and a family member helped Patient B walk to the rest room."(Patient B) was having a lot of problems ambulating after the initial fall (at assisted living)." RN 1 also stated the patient didn't have her walker. When the patient was in the rest room, RN 1 "heard fumbling and calling out...I grabbed her shoulders but her buttock was already on the ground."

The ED report dated January 27, 2010 for Patient B was reviewed on March 4, 2010. The report indicated that (before the fall in the restroom) the patient was having extreme pain with ambulation, and severe pain with standing, which did improve with medication. The diagnostic impression was incomplete fracture of the left bony process below the neck of the thigh bone. After the fall in the rest room, a subsequent x-ray revealed an additional small fracture at the neck of the thigh bone, and the patient would be hospitalized.

A history and physical indicating that Patient B would be admitted to the hospital also noted that the patient was unable to bear weight.

During an interview with a facility radiologist (Rad 1) on March 4, 2010 at 1:30 PM, he stated "You could say the fall (in the ED) caused more pain and suffering...The fall could have made the bones move more."