Samaritan Medical Center

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 48296 Based on medical record review (MR) and interview, in 1 of 10 MRs (Patient #1), the facility failed to determine who could make medical decisions for a patient and what health care decisions could be made. This could lead to a patient’s wishes concerning their provision of care to not be followed. Findings include: -- Per MR review, on 3/28/2025 Patient #1 presented to the emergency department (ED) via emergency medical services (EMS) with nausea and vomiting and increased work of breathing. Patient #1 was triaged as an emergency severity index (ESI- algorithm for ED patients to determine the severity of presenting illness and ED needs) of 3 (1-emergent, 5- non-urgent). Patient #1 had a past medical history of cognitive impairment, small bowel obstructions without surgical intervention, and prior sigmoid colectomy. Patient #1 was diagnosed with influenza A, possible pneumonia, and CT revealed a high-grade small bowel obstruction (complete obstruction in the bowel). Patient #1 was admitted to the hospital. A surgical consult was completed. There was a potential need for surgical intervention, which was discussed with Patient #1’s sibling. Another CT was completed which revealed the small bowel obstruction was worse. Patient #1 was scheduled for surgery for 4/3/2025. Verbal consent was obtained from their sibling. Patient #1 was taken to the operating room for a laparoscopic repair of their small bowel obstruction. During surgery, a complication occurred that resulted in conversion to an open exploratory laparotomy. Following their procedure, Patient #1 was brought to the intensive care unit (ICU) for monitoring and supportive care. On 4/5/2025, Patient #1 was seen by an intensivist who noted they were starting to show signs of septic shock. A CT scan of their abdomen revealed changes from a small bowel resection with ascites and evidence of peritonitis (infection of the peritoneal lining in the abdomen). The findings were compatible with peritonitis related to a post-operative leak. Patient #1 was seen by Staff A, Clinical Staff, following new onset sepsis (bloodstream infection), Staff A spoke with Patient #1’s sibling extensively regarding the concerns that if Patient #1 does not have operative intervention, that it will be a terminal issue and Patient #1 will die from sepsis. Patient #1’s sibling declined surgery and opted for supportive care. Aggressive supportive care was provided to Patient #1. On 4/9/2025 at 12:17 pm, Staff B, Clinical Staff, reached out to Patient #1’s residential facility to clarify who can make medical decisions for them. Patient #1 did not have a health care proxy (HCP). Patient #1’s sibling can make medical decisions unless the recommendation is to withhold treatment or change code status. At 2:47 pm, a surgeon discussed Patient #1’s legal status who was a “ward of the state” and their sibling could not “withhold treatment”. The surgeon opined it was reasonable for Patient #1 to go to the OR for surgical intervention. The plan was discussed with Patient #1’s sibling who agreed and consent was obtained. Patient #1 was taken to the OR for repair of their small bowel. The MR lacked documentation of a HCP or medical decision making documention when surgery was withheld on 4/5/2025. -- During interview of Staff C, Quality Personnel, on 9/16/2025 at 2:00 pm, they confirmed Patient #1 did not have a health care proxy.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 49168 Based on document review, medical record review, and interview, the hospital did not comply with the requirements at 489.24 and 489.20, Specifically, 1) In 3 of 21 (Patient #1, Patient #3, and Patient #4) medical records reviewed of patients who presented to the emergency department (ED), the hospital failed to provide a timely medical screening exam (MSE) to determine if an emergency medical condition existed. 2) In 1 of 4 (Patient #5) medical records reviewed of patients who were transferred to a higher level of care, it lacked documentation of the benefits and risks of transfer specific to the patient’s medical condition. Please reference findings at Tag 2406 and Tag 2409.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 49168 Based on document review, medical record review, and interview, the facility failed to implement a process to ensure prompt triage and medical screening exam (MSE) of patients who walk into the emergency department (ED). Specifically, 1) In 3 of 21 (Patient #1, and Patient #3) medical records reviewed of patients who presented to the ED the facility failed to provide a timely MSE to determine if an emergency medical condition existed. Findings include: -- Review of the facility’s policy and procedure titled, “Emergency Department Standard of Care,” revised 2/23/2023, indicated “patients arriving to the Emergency Department (ED) will be triaged by a RN [registered nurse] and receive an Emergency Severity Index (ESI) number based on their presentation to the ED.” Emergency Severity Index is a a tool used to prioritize patients based on signs/symptoms ranging from 1 - resuscitation to 5 - non-urgent. -- Per interview of Staff C, ED, RN, on 9/18/2024 at 1:30 pm, the process for ED walk ins is that patients walk into the ED then sign in by filling out the presentation form with their information and chief complaint then place the completed form into a basket. The emergency department aide (EDA) will get the completed presentation forms from the basket and see the patients one at a time to get their vital signs (VS) and start the registration process. Staff C explained the EDA can be backed up due to being busy and the registration process can take up to 15 minutes per patient. Staff C stated the EDA may show the RN what a patient wrote down for a chief complaint if it is a potential priority, but otherwise the RN will start triage after the patient is registered. Staff C indicated having concerns for delay in patient assessments and discussed it with the former ED manager. -- Per interview of Staff E, ED, RN, on 9/18/2024 at 3:15 pm, they described the current ED walk in process. Patients present and fill out the presentation form with their information and complaint, and drop the form in the basket. An EDA picks up the forms to review the complaints, then gets the patient to do their VS and quick registration. The EDA will notify the RN of any potential critical concerns. The RN then performs triage. Findings specific to Patient #1: -- Review of Patient #1’s medical record revealed, Patient #1 presented to the ED on 5/15/2024 at 12:45 pm and documented their reason for visit being “pain” on the Emergency Patient Presentation Record form. At 1:49 pm, staff obtained Patient #1’s VS - blood pressure (BP) 80/50, pulse (P) 79, respirations (R) 20, and temperature (T) 98.2. At 1:54 pm, an RN triaged Patient #1 as a level 3 on the ESI scale. Patients #1 presenting complaint was abdominal pain radiating to the back since that morning. Patient #1 reported their pain intensity being an 8 (0 - no pain, 10 - most painful). At 2:16 pm, Patient #1 was assigned a bed in the ED and had VS obtained every 2 - 5 minutes by ED RN until being transferred. At 2:35 pm, 1 hour and 50 minutes after arrival to ED, Patient #1 was seen by a provider for their MSE. Patient’s condition was listed as critical with diagnosis of dissecting ascending aortic aneurysm (tear occurs in the body’s main artery). At 2:36 pm, the provider ordered imaging, a computed tomography angiography (CTA) of the abdomen and pelvis. Reason for exam listed hypotension and abdominal pain into the back, rule out dissection. At 3:04 pm, CTA was completed with findings of a dissecting aneurysm extending from the thoracic aorta and both common iliac arteries. At 3:28 pm, Patient #1 required intubation (medical procedure to keep airway open) due to respiratory failure after developing hemoptysis (coughing up blood) and needing airway protection. At 3:40 pm, the provider ordered to transfer Patient #1 to a higher level of care facility for vascular surgery evaluation. At 4:00 pm, Patient #1’s was transferred. -- Per interview of Staff B, ED, RN, on 9/18/2024 at 10:45 am, they remembered caring for Patient #1 in the ED. Staff B stated Patient #1 waited in the waiting room longer than desired before being seen by the triage RN. Staff B stated Patient #1 was very pale, hypotensive (low BP), and complaining of extreme pain 10 out of 10 upon coming from the waiting room into the main ED. Staff B indicated Patient #1 was slowly given intravenous (IV) fluids to help support their BP but went into flash pulmonary edema (fluid builds up in the lungs) and needed to be intubated. Staff B indicated a provider was in with Patient #1 ordering testing to rule out a dissection soon after being brought to a room in the main ED. Patient #1 had a CTA and then was transferred to a different facility due to the dissection. -- Per interview of Staff F, ED, Provider, on 9/18/2024 at 4:00 pm, Patient #1 looked very ill when they walked back in to the main ED. Staff F recalled having immediate concerns for Patient #1 having a dissected aneurysm. Staff F indicated Patient #1 was hypotensive, began complaining of shortness of breath, and developed flash pulmonary edema requiring intubation. Staff F reached out to another facility’s vascular department and then started the transfer process. Staff F indicated the ED walk in process has loopholes resulting in patients being able to blend into the crowd in the waiting room, without any staff seeing how sick they really are. -- Per interview of Staff I, EDA, on 9/19/2024 at 11:45 am, the quick registration along with getting a patient’s VS takes 10 - 20 minutes depending on the patient’s needs. Staff I indicated being 10 papers deep when the walk-in area has multiple patients waiting to be registered before being triaged by the RN. Staff I remembered Patient #1 presenting to the ED with complaint of abdominal pain and instructing them to fill out the presentation form. Staff I indicated Patient #1’s appearance at time of walking into the ED did not raise any flags for concern. Staff I recalled Patient #1 waiting about 1 hour to have VS done and be quick registered. At that time, the patient’s BP that was an immediate red flag. -- Per interview of Staff J, Vice President (VP) of Medical Affairs and Chief Medical Officer (CMO), on 9/27/2024 at 11:30 am, leadership is monitoring the ED wait time and identified it was too long. Staff J indicated hypotensive patients should be seen within minutes of walking into the ED. Findings specific to Patient #3: -- Review of Patient #3’s medical record revealed, Patient #3 presented to the ED on 8/13/2024 at 10:50 am with chief complaint of chest pain. At 11:30 am, Patient #3 began the registration process with the EDA. Patient #3’s VS were BP 170/99, P 74, R 18, and T 97.8. At 11:44 am, Patient #3 had an EKG completed by the EDA. At 11:46 am, Patient #3 was triaged by RN noting the presenting complaint of “chest pressure starting last eveing while at rest ... intermittent pressure since.” Patient #3 was assigned an ESI score of 2. At 12:11 pm, 1 hours and 21 minutes after arrival to ED, Patient #3 was seen by provider for their MSE. At 3:54 pm, Patient #3 was transferred to another facilty with a discharge diagnosis of non-ST-elevation myocardial infarction (NSTEMI) (type of heart attack). -- Per interview of Staff J, VP of Medical Affairs and CMO, on 9/27/2024 at 11:30 am, they acknowledged the above findings.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 48296 Based on medical record review, document review and interview, in 1 of 4 (Patient #4) medical records reviewed of patients who were transferred to a higher level of care, 1 lacked documentation of the benefits and risks of transfer specific to the patient’s medical condition. This could lead to patients not being informed of potential risks and benefits related the transfer. Findings include: -- Per review of Patient #4’s medical record, they presented to the emergency department (ED) on 5/31/2024 at 11:05 am with a chief complaint of dizzy spells. The provider determined Patient #4 needed to be transferred to a higher level of care for a transischemic attack (TIA- a temporary blockage of blood flow to the brain) and a carotid aneurysm (a bulge in one of the arteries supplying blood to the brain and nearby structures). The transfer form titled “Interfacility Transfer,” dated 10/2022, under the section titled “Risks” contained a generic statement of “MVA [motor vehicle accident] and decompensation enroute”. The section titled “Benefits” contained a generic statement of “vascular”. The provider did not document the specific risks and benefits of transfer that related to this patient’s condition. -- Review of the facility’s policy and procedure titled “Transfers,” dated 2/25/2022, indicated (in part) “any EMTALA [Emergency Medical Treatment and Active Labor Act] Transfer will meet the requirements of an appropriate transfer including the patient or other appropriate parties’ consent to the transfer and the qualified medical profession (QMP) certification of the risks and benefits of the transfer ... “ -- Per interview of Staff J, Vice President (VP) of Medical Affairs and Chief Medical Officer (CMO), on 9/27/2024 at 11:35 am, it can be difficult to get the physicians to document properly. There is a mandatory physician education packet that includes documenting the specific risks and benefits. Staff J acknowledged these findings.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 46619 Based on medical record review, document review, interview, and observation, the facility failed to ensure compliance with the Condition of Participation of Emergency Services. Specifically, the facility failed to implement fall prevention interventions in the emergency department (ED) for 4 patients who had been identified as being at high risk for falls. (Patient #2, Patient #3, Patient #4, and Patient #5). The hospital’s policy and procedure failed to specify what fall prevention interventions should be implemented in the ED based on results of the “Memorial Emergency Department Fall Risk Assessment,” (MEDFRAT- tool used in EDs to identify patients at high risk for falls) which must be completed on every adult patient (18 years or older) who is admitted to the ED. Failing to implement measures to prevent falls in the ED places patients at risk for falls. Findings include: -- Hospital staff failed to implement fall precautions, after recognizing a patients (Patient #2) high risk for falls. -- Hospital staff failed to implement fall precautions for 3 additional patients (Patient #3, Patient #4, and Patient #5) in the ED. Each of these patients had been identified by their assigned registered nurse (RN) as being at high risk for falls. -- Review of the facility’s policy and procedure titled “Inpatient Fall Management,” revised 5/19/2023, revealed that it does not specify what fall prevention interventions should be implemented after an RN completes the MEDFRAT to evaluate the fall risk of a patient n the ED. See Tag A1104.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 46619 Based on document review and interview, in 1 of 1 hospital investigations reviewed, it was determined that the hospital did not identify all contributing factors that impacted this event. Findings include: -- Review of the hospital’s policy and procedure titled “Safety Event Reporting,” revised 10/2022, indicated each event will be investigated and corrective actions will be implemented by the responsible department when indicated. -- Review of a hospital’s investigation report,(undated), indicated a patient had an adverse event. The report identified one contributing factor to the event. Additional contributing factors were not identified and therefore staff were not provided with education to prevent a similar event. -- Per interview of Staff B, CT Technician, on 9/17/2024 at 10:00 am, in this event, the involved patient was not wearing a red bracelet to indicate they were at high risk to fall and they were not provided report regarding the patient’s mobility. -- Per interview of Staff A, Patient Safety Officer, on 9/20/2024 at 4:30 pm (and at other times throughout the survey), they confirmed no action was taken to provide education to nursing staff about fall prevention interventions in response to this investigation.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 46619 Based on medical record review, document review, observation, and interview 1) in 1 of 21 (Patient #2) medical records reviewed, hospital staff failed to implement fall prevention interventions to prevent the patient from falling in the emergency department (ED), 2) in 3 of 3 (Patient #3, Patient #4, and Patient #5) observations, hospital staff failed to implement fall prevention interventions, and 3) the hospital’s policy and procedure failed to specify what fall prevention interventions should be implemented in the ED, based on results of the required fall risk assessment. This contributed to a patient fall in the ED. Findings for (1) include: -- Per medical record review, on 7/11/2024 at 11:59 pm Patient #2 presented to the ED via ambulance with a chief complaint of altered mental status. Family reported history of high ammonia levels and similar episodes of altered mental status as a result in the past. The patient takes Lactulose (a medication used to reduce the amount of ammonia in the blood of patients with liver disease) three times a day as treatment for cirrhosis (scarring of the liver that causes it to fail). Registered nurse (RN) documented patient was confused, disoriented, and appeared distressed. Behavior was agitated and uncooperative. Patient was unable to answer questions. Vital signs (vs) were blood pressure (BP) 116/78, Pulse (P) 93, Respirations (R) 20, temperature (T) 97.8 degrees, oxygen saturation 98% on room air. On 7/12/2024 ED Physician Record (no time indicated) revealed: Chief Complaint: decreased mental status, confused. History obtained from significant other who noted patient was difficult to awaken and confused this morning. At baseline, patient is alert and oriented and walks without assistance. Past medical history includes cirrhosis of liver. Physical exam: lethargic, not speaking, thrashing around. Moving all four extremities, unable to assess strength, sensation, or weakness as patient unable to comply with neurological exam due to confusion. Wounds on both feet. Chest x-ray normal. Electrocardiogram (EKG) normal. Clinical impression: Hepatic Encephalopathy (loss of brain function when damaged liver doesn’t remove toxins, including ammonia, from the blood) with high ammonia level. Patient admitted. 7/12/2024 at 12:41 am: Registered nurse documented neurological assessment: Altered mentation, confused, arousable to name, but unable to evaluate comprehension. Unable to maintain eye contact. No facial droop. Behavior is restless. Glasgow Coma Scale (GCS) was 10 (tool used to score level of consciousness based on eye response, verbal response, and motor response. Scores range from 3 to 15 with a higher score indicating higher level of consciousness). “Memorial Emergency Department Fall Risk Assessment Tool” (MEDFRAT) [fall risk assessment tool used to evaluate an ED patient’s risk for falls] fall risk assessment: RN entered “yes” to indicate patient was confused/disoriented, intoxicated or sedated, and had impaired gait. RN documented “no” mobility assistance devices used, no alterations in elimination. Unable to assess fall history at this time. Fall risk score of 14; Fall risk indicators documented as “high”. Fall prevention interventions: Bed in low position, siderails up, call light in reach, and non-skid-footwear. (Note: These are universal fall prevention interventions according to hospital, Fall Prevention Program education) 7/12/2024 at 3:20 am: Registered nurse documented reassessment, patient was alert to name, but remains unable to answer basic orientation questions or follow commands. 7/12/2024 at 4:35 am: Computed tomography (CT) scan of head ordered: Reason for exam was altered mental status. Computed tomography scan of abdomen and pelvis ordered: Reason for exam was altered mental status and loose stool. Physician indicated transport by stretcher as patient is unable to stand without assistance. 7/12/2024 at 4:39 am: Registered nurse entered order for Fall Precautions. 7/12/2024 at 5:55 am: Admission History and Physical (in part): Patient is a 68-year-old with known nonalcoholic cirrhosis who was brought to the ED for altered mental status. Husband noted patient’s behavior was not at baseline earlier and realized Lactulose had not been taken in several days. Patient was awake but confused, unable to respond to questions with appropriate responses. Past medical history: Cirrhosis with history of hepatic encephalopathy, chronic thrombocytopenia (low platelets due to liver disease, leads to increased risk for bruising and bleeding), chronic lower back pain with severe peripheral neuropathy (weakness, numbness, and nerve pain, often affecting hands and feet). Abnormal findings from exam: awake, but restless, inattentive, shuffling in bed, not following commands, sleepy. Neuro status: awake, speaks one word from time to time, not answering questions. 7/12/2024 at 5:55 am: Registered nurse documented patient remained anxious and restless. Patient extremely confused. Patient attempting to get out of bed frequently and had to be redirected to expel fluids while in bed. Emergency department assistant (EDA) at bedside with patient for safety. 7/12/2024 at 6:59 am: Registered nurse documented patient calm and resting. Emergency department assistant relieved from sitting with patient. 7/12/2024 at 7:42 am: Registered nurse documented altered mental status continued. When asked name and date of birth, patient only provided date of birth. Patient went to have CT and fell while tech was moving the ED stretcher away from the CT table. Patient rolled off, approximately 2 feet, on to right side. Patient did not strike head or lose consciousness. Physician notified of fall and mental status exam. 7/12/2024 at 7:51 am: Computed tomography scan of spine ordered: Reason for exam was fall, new complaint of neck pain. Rule out fracture. 7/12/2024 at 8:16 am: VS: BP 187/77, P 97, oxygen 99%. -- Per review of the facility’s policy and procedure titled “Inpatient Fall Management,” revised 5/19/2023, upon admission to the ED and/or all inpatient units, a RN will conduct a fall risk assessment on each patient ... All fall precaution interventions, as determined by the level of fall risk and individual needs, must be implemented ... In the ED, the MEDFRAT fall risk assessment must be completed on every adult patient (18 years or older) who is admitted to the ED. The hospital’s policy and procedure lists does not list fall prevention interventions that correspond to the scores for the MEDFRAT, which is used to categorize patients’ fall risk in the ED setting. -- Per interview of Staff B, CT Technician, on 9/17/2024 at 10:00 am, Patient #2 was not wearing a red bracelet to indicate they were at high risk to fall. Typically, RNs give report and/or help transport, but they were not available to do so for this patient. --Per interview with Staff C, Chief Nursing Officer, on 9/27/2024 at 10:15 am (and at other times during the survey), they acknowledged these findings. Findings for (2) include: -- During observation of Staff D, ED RN, at 9:50 am on 9/27/2024, they transported a patient (Patient #3) with altered mental status from the CT scanner to their room in ED. The patient was noted not to be wearing a falls risk bracelet. -- Per interview of Staff D, at 9:55 am on 9/27/2024 , Patient #3 was at high risk for falls as they presented to the ED (within the prior 45 minutes) with neurological changes that indicated possible stroke. Staff D indicated fall prevention interventions should be implemented once a patient has been identified as at high risk for falls, however, they prioritized the patient’s diagnostic work up. With the need for urgent imaging, fall precaution interventions had not yet been fully implemented. Staff D indicated their patient assignment included three other ED patients: 2 of these 3 patients (Patient #4 and Patient #5) were identified as being at high risk for falls, 1 of the 3 patients was at low risk for falls. -- Per interview of Staff A, Patient Safety Officer, on 9/20/2024 at 4:30 pm (and at other times throughout the survey), Staff A acknowledged the hospital’s policy and procedure does not specify which fall prevention interventions correspond to the scores for the MEDFRAT, which is the fall risk assessment used by RNs in the ED. Staff A acknowledged, like the hospital’s policy and procedure, the fall prevention education, which all staff complete, describes only interventions which correspond with the results of the MORSE and Humpty Dumpty fall risk assessments. Staff A confirmed there is no separate education that addresses fall prevention interventions in response to the patient’s risk score as determined by the MEDFRAT. Staff A indicated that ED staff should be putting fall prevention interventions in place for patients who are, based on the MEDFRAT fall risk assessment, at high risk for falls. Fall prevention interventions for patients at high risk to fall include using fall risk bracelets, non-slip socks, and indicating with signage, on the patient’s door and at the head of the bed, that they are at high risk to fall (among others as appropriate to individual patients). These interventions should be chosen from drop down choices within the medical record to document which fall prevention interventions were put in place by ED staff. Staff A acknowledged this could lead to patients without appropriate fall prevention measures in place in the ED. -- Per observations in the ED, between 9:50 am and 10:45 am, 2 patients (Patient #4 and Patient #5), who were identified as being at high risk for falls by Staff D, lacked appropriate fall prevention interventions. Neither patient’s door had any indication (i.e., signage, magnet, or sticker) that would alert staff of their high risk for falls. Neither patient was wearing a fall risk bracelet or non-slip socks. -- Per interview of Staff C, on 9/27/2024 at 9:55 am, they indicated additional fall prevention interventions should have been implemented, in addition to the standard fall prevention interventions, due to the patients’ high fall risk. Staff C acknowledged the above findings. Findings for (3) include: -- Review of the facility’s policy and procedure titled “Inpatient Fall Management,” revised 5/19/2023, indicated “the purpose of the policy is to provide guidance to hospital staff on how to prevent falls, to reduce potential for patient injury from a fall, and to provide the framework for assessing risk factors for falls, implementing interventions for reducing the risk for falling, and protecting patients from injury if a fall should occur. Fall prevention procedures are based on the assessment of the patient, determination of the patient’s risk for fall, and implementation of interventions that reduce the intrinsic and extrinsic risks identified ... Upon admission to the ED and/or all inpatient units, a RN will conduct a fall risk assessment on each patient using the electronic medical record. All fall precaution interventions, as determined by the level of fall risk and individual needs, must be implemented. ... In the ED, the MEDFRAT fall risk assessment must be completed on every adult patient who is admitted to the ED. On the inpatient units, the MORSE fall risk assessment must be completed by a RN on every adult patient admitted to an inpatient unit; the level of fall risk is determined by the patient’s MORSE score. The Humpty Dumpty fall risk assessment is used for pediatric patients (less than 18 years old). Universal Fall precautions education and interventions apply to all patients. “ The hospital’s policy and procedure lists specific fall prevention interventions that should be implemented based on results (the numerical score) of the MORSE and Humpty Dumpty fall risk assessments, but does not specify which fall prevention interventions correspond to the scores/risk categories that are derived from for the MEDFRAT fall risk assessment, which is used to categorize patient’s fall risk in the ED setting. -- Per review of “Fall Prevention Program,” revised 3/2023, which outlines the content of the mandatory annual staff training, “the Fall Prevention Program is hospital wide. All employees are responsible for identifying risk factors in the facility and must implement Universal fall Precautions in their respective work areas.” The hospital’s training lists specific fall prevention interventions that should be implemented based on results (the numerical score) of the MORSE and Humpty Dumpty fall risk assessments but does not specify which fall prevention interventions correspond to the scores/risk categories that are derived from for the MEDFRAT fall risk assessment, which is used to categorize patient’s fall risk in the ED setting. -- During interview of Staff C, Chief Nursing Officer, on 9/27/2024 at 4:30 pm (and at other times throughout the survey) they indicated the falls education does not specify which interventions correspond to risk categories that are determined by the ED patient’s score on the MEDFRAT. Staff C indicated that there is not a separate educational program for ED staff that addresses fall prevention interventions. Staff C acknowledged this could lead to inconsistent implementation of fall precautions and fall prevention interventions within the ED. Staff C acknowledged the above findings.”