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Based on document review and interview, nursing services failed to ensure fall prevention safety measures were implemented, failed to document a patient's fall(s) in the Event Report Log, and failed to notify the attending provider after a patient fall in 1 of 10 medical records reviewed (patient 5).

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview, nursing services failed to ensure fall prevention safety measures were implemented, failed to document a patient's fall(s) in the Event Report Log, and failed to notify the attending provider after a patient fall in 1 of 10 medical records (MRs) reviewed (patient 5).

Findings include:

1. Facility policy titled: ED Fall Prevention Protocol, last reviewed 3/11/2022, indicated under I. Assess a. The Memorial Emergency Department Fall Risk Assessment tool should be used at the following times to help predict which patients are at risk of falling: i. Upon admission to the Emergency Department. ii. After a fall occurs.

2. Facility policy titled: Fall Event Management Protocol, last reviewed 04/2022, indicated under Managing a Fall B. When a fall happens, Colleagues involved, the House Supervisor, and the family/patient discuss the event in a huddle immediately following the event. A risk event report is completed, which includes a post-fall huddle tool. The tool guides the conversation between members of the huddle to identify the type of fall (developmental, physiological, suspected intention or unintentional). Risk factors and defects contributing to the fall are also identified. The tool guides the huddle members to discover additional interventions to prevent further falls for the patient. C. Action to take by role: 2. Registered Nurse. b. Notify the attending or covering physician or nurse practitioner. e. Document the fall event and huddle results in risk event in Infohub or Midas. f. Reassess fall risk and injury risk and update patient's care plan. D. Communication: Clear and timely communication with the family preserves families' trust. 1. A physician or nurse practitioner is always to be notified of the fall. They will assess the patient based on collaborative discussion with the RN. Definitions: Fall: A sudden, unintentional descent, with or without injury to the patient, which results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can). When a patient rolls off a low bed onto a mat or is found on a surface where you would not expect to find a patient, this is considered a fall. If a patient who is attempting to stand or sit falls back onto a bed, chair or commode, this is only counted as a fall if the patient is injured. Fall Types: 2. Physiological: A fall attributable to one or more intrinsic, physiologic factors (e.g., hypotension, dysrhythmia, seizure, TIA/stroke, side of effect of certain medications, delirium, intoxication, dementia, gait instability, or visual impairment).

3. Review of patient 5's MR indicated the following:
a. patient presented to facility ED (Emergency Department) on 12/10/24 at approximately 8:00 pm with complaint of headache and seizure, fall at home earlier in the day, chest pain, low back pain and muscle spasms. MR indicated patient fell, while at facility, from wheelchair at approximately 8:16 pm and 8:58 pm, and a fall from patient's bed at approximately 9:15 pm, on 12/10/24. MR lacked documentation of provider notification after patient's 2nd and 3rd fall.

b. MR lacked documentation of fall prevention safety measures assessed/implemented until after patient's 3rd fall.

4. Administrative document review lacked documentation of Event Reporting related to patient 5's three falls during facility visit on 12/10/24.

5. In interview on 1/23/25 at approximately 2:00 pm, A1 (Director of Clinical Quality) confirmed there were no Event Report of P5's falls during ED visit on 12/10/24, per policy.

6. In telephone interview on 1/24/25 at approximately 12:52 pm to 1:03 pm, N7 (Registered Nurse) confirmed he/she did not create an Event Report for P5's fall from bed, and thought the charge nurse had reported this event.