Based on medical record review, document review and interview, in one (1) of three (3) medical records reviewed, the facility failed to ensure that: (a) staff in the Emergency Department (ED) implement an individualized Fall Prevention plan of care for patients at risk for falls, (b) revise their fall prevention policy to reflect current changes in fall management that were identified by the facility, and (c) provide training to staff on the current changes. (Patient #1). Findings include: Review of the medical record for Patient #1 identified: a 90 year/old female brought to the hospital emergency room on [DATE] via ambulance at approximately 8:51 PM after a syncopal event at home. Patient has past medical history of: Diabetes, Coronary Artery Disease, Brain Aneurysm. The Nursing triage assessment signed at approximately 8:57 PM, assessed the patient as potential for falls and high risk for injury. The nursing assessment categorized patient as "Fall with harm risk" with indicators: patient needing assistance with walking/toileting, fallen in the past 6 months, mental confusion/attempting to get out of bed unassisted, [AGE] years and older, coagulopathy, bone disease, surgical intervention, disease process. The Fall Risk Plan of Care initiated on 1/9/19 at 11:17 PM by Staff E, patient's primary nurse stated "fall risk: progress to goal. Absence of falls, making progress towards outcome. Plan of care ongoing interventions implemented as appropriate." The plan of care did not document the fall risk interventions that were implemented and the monitoring provided. On 1/10/19, nursing plan of care note signed at 02:05 AM, stated "call bell going off again. Spoke with patient via interpreter phone and reassured her daughter will be here at 7:00 AM." On 1/10/19, progress nursing note documentation timed 5:15 AM, stated "patient agitated and ripped out I.V. (intravenous line), took off bracelet, ripping off 02 sat (oxygen saturation). Called interpreter, discussed situation with patient, patient states she wants to go home, told patient daughter will be coming at 7:00 AM. Instructed how a new I.V. (intravenous line) will be placed. Will continue to monitor." There was no evidence of nursing reassessment for changes in mental status and no update in the plan of care. On 1/10/19, nursing documentation signed at 8:17 AM, stated "patient had an unwitnessed fall at 6:58 AM." The Physician Assistant note dated 1/10/19 at 8:40 AM, stated "[AGE]-year-old female s/p unwitnessed fall from stretcher at the bottom of the bed, per medical /ED team, patient is confused now, was not confused prior to fall." Patient had Cat-scan of the head, spine and neck angiogram and was diagnosed with C2 vertebrae fracture without need for surgical intervention. Review of the policy titled: "Fall Prevention-Inpatient/Resident," dated 1/25/17, states: Plan of Care: - All patients/residents who are assessed as being at risk for falls should be an individualize fall prevention plan of care to prevent the occurrence of falls and harm from falls, and to promote safety. - The plan will be an interdisciplinary approach and should be documented in the appropriate areas in the medical record. - The plan will include input from the inpatient/resident/caregiver/family and should include: (a) Identified risks. (b) Interventions appropriate to the inpatient's/resident's needs based on Fall/Harm Risk Assessment. © Documentation of the Assessment Category and Interventions on the Fall/Harm Risk Assessment and Intervention Form. The documentation in the medical record did not show evidence of the assessment, interventions and monitoring to prevent falls. During interview on 4/12/19 at approximately 11:32 AM, on the injurious fall of patient #1, Staff D, Emergency Department Manager responded "it was a devastating fall and we had done extensive review of the case. Patients were previously assessed once per shift since our nurses work the 12-hour shift, but now the assessment is on an ongoing basis during each shift with hourly rounding documentation. We also hold daily huddle and look at each high-risk patients' criteria like the confused patients that cannot be easily directed or is at risk for self-harm. We categorize them as possible 1:1 care." There was no documented evidence that the policy "Fall Prevention-Inpatient/Resident," dated 1/25/17 has been revised to reflect these changes. There is no documented evidence that staff training has been provided.

Based on interview, review of medical record and other documents, it was determined the facility failed to ensure that each patient presenting to the Emergency Department (ED) and determined to have an Emergency Medical Condition receives stabilizing treatment prior to discharge. This finding was noted in 1 of 29 applicable records (Patient #4). Findings include: Patient #4 is a [AGE]-year-old male who (MDS) dated [DATE] at 7:57 PM with complaint of abdominal pain. Labs revealed an elevated WBC at 12.33 thymus-helper cells/millimeter cubed (t-h/mm3). Surgical consult was obtained after an abdominal sonogram revealed cholelithiasis (presence of gallstones) and gallbladder sludge with wall thickening and edema. The radiologist recommended clinical and laboratory correlations and a Hepatobiliary Iminodiacetic Acid Scan (HIDA - a scan that creates pictures of the liver, gallbladder, biliary tract and small intestine) to be obtained for further evaluation. Although the clinical impression of the surgical consultant was, "questionable biliary colic versus acute [DIAGNOSES REDACTED] (inflammation of the gallbladder)" and a plan was proposed to admit patient, start intravenous fluids, and intravenous antibiotics, the patient was discharged home on 8/30/14 at 05:59 AM. The patient did not receive antibiotic treatment in the ED and HIDA scan was not obtained as recommended by the radiologist. The patient's discharge instruction included prescriptions for Pepcid (an acid reducer) and Nulev (an anti-spasmodic indicated for cramping pain caused by kidney stones). The patient was instructed to follow-up next week with a surgeon for reevaluation and further treatment. During the ED course, the patient was medicated five times with intravenous Morphine sulfate and Hydromorphone (opioid analgesics). At interview with Staff #3, surgical consultant, on 2/20/15 at 10:45 AM, she stated she saw the patient in the Emergency Department on 8/30/14 and determined patient required admission for treatment of an infectious process related to what she thought could be biliary colic versus acute [DIAGNOSES REDACTED]. She stated that she later authorized the patient's discharge because the patient was pain free and wanted to go home. She added that the patient was given a referral for follow up care and management of his medical condition. She admitted that no antibiotic was ordered for the treatment of the infectious process. The patient returned to the ED on 8/30/14 at 10:09 AM, four hours after discharge, with complaint of increasing abdominal pain. Labs revealed elevated WBC at 16.5 t-h/mm3. CT scan of the abdomen and pelvis revealed distended gallbladder with stones and surrounding inflammatory changes. These findings, when correlated with abnormal ultrasound, were highly suspicious for acute [DIAGNOSES REDACTED]. The patient was admitted for acute abdomen, peritonitis (inflammation of the membrane which lines the inside of the abdomen), and sepsis (systemic inflammatory response caused by infection). He underwent laparoscopic subtotal cholecystectomy (removal of the gallbladder by laparoscopy) on 8/30/14. Intraoperative findings included [DIAGNOSES REDACTED], with peritonitis, and gallbladder wall gangrene.