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Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by a registered nurse failing to implement fall risk interventions after performing fall risk assessment and prior to a patient fall for 1 (#3) of 3 (#1-#3) sampled patients with falls in the ED.
Findings:

Review of the hospital policy titled Emergency Department Assessment Standards with an approval date of 10/27/2023 revealed, in part:
I. Purpose. The purpose of this policy is to establish assessment guidelines for patients presenting to the Emergency Department (ED).
III. Policy Statements. 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.

Review of Patient #3's medical record revealed the patient was an 80 year old female that presented to the hospital ED on 02/09/2024 at 12:47 a.m. with a chief complaint of palpitations.

Review of Patient #3's medical record revealed a Fall Risk Assessment on 02/09/2024 at 1:19 a.m. Review of the fall risk assessment revealed, in part: Polypharmacy: Yes; Cardiovascular Medication: Yes; Age Greater Than 65 Years: Yes. Further review of the fall risk assessment revealed no fall prevention interventions documented at time of assessment.

Review of Patient #3's medical record revealed, in part, on 02/09/2024 at 2:53 a.m. Patient #3 had a fall in the restroom and reported pain to right shoulder from hitting the ground.

Review of Patient #3's ED Provider Notes dated 02/09/2024 revealed, in part, Patient #3 went to the restroom and fell off of the toilet injuring her right shoulder. The patient had difficulty moving her right shoulder. X-ray ordered, awaiting results.

Review of Patient #3's X-Ray Shoulder dated 02/09/2024 revealed, in part: Impression: Acute fracture of the humeral neck.

In an interview on 04/17/2024 at 10:03 a.m., S4ED Manager confirmed Patient #3's Fall Risk Assessment done on 02/09/2024 at 1:19 a.m. did not contain fall interventions. S4ED Manager confirmed a RN should have completed the fall risk assessment with fall interventions prior to Patient #3 falling.

Based on record review and interview, the hospital failed to provide all necessary medical information pertaining to the patient's current course of treatment and post-discharge care, at the time of discharge, to the appropriate post-acute care service provider. This deficient practice was evidenced by failing to notify the long term care facility where the patient resided at time of discharge of an unwitnessed fall in the ED and by failing to provide fall discharge instructions for 1 (#1) of 3 (#1-#3) discharged patients sampled.
Findings:

Review of the hospital policy titled Admission, Discharge and Transfer Guidelines for the Emergency Department with an approval date of 09/14/2023 revealed, in part:
I. Purpose. The purpose of this policy is to establish guidelines for the admission, discharge, and transfer of patients presenting to the Emergency Department (ED).
D. Discharge: 2. Discharge instructions will be reviewed with the patient or responsible party upon discharge. These instructions may include the following information:
a. Instructions pertinent to the patient's illness/injury.
3. The discharging nurse will ensure that the patient or responsible party understands the discharge instructions.
4. The patient or responsible party will be provided with a copy of their discharge instructions and any applicable educational materials.

Review of Patient #1's medical record revealed the patient was an 86 year old male that presented to the hospital ED on 02/19/2024 at 5:32 p.m. with a chief complaint of abdominal distention. Patient #1 was a resident of a long term care facility.

Review of Patient #1's medical record revealed an ED Post Fall Summary on 02/19/2024 at 8:31 p.m. Further review revealed the patient had an unwitnessed fall out of the bed and found on the floor in the room.

Review of Patient #1's medical record revealed no evidence the long term care facility where the patient resided or the patient's listed family contacts were notified of the fall or provided fall discharge instructions at time of discharge.

Review of Patient #1's After Visit Summary (discharge instructions) revealed no post-care instructions for fall.

In an interview on 04/17/2024 at 3:47 p.m., S4ED Manager confirmed neither the long term care facility where Patient #1 resided nor Patient #1's family contacts were notified of the fall at the time of discharge. S4ED Manager confirmed the discharge instructions provided did not address fall.

Review of hospital documentation provided by S2Quality Manager revealed, in part, that on or around 02/27/2024, the hospital obtained information from the long term care facility Patient #1 had a fractured pelvis.