HospitalInspections.org
Bringing transparency to federal inspections
KAISER SUNNYSIDE MEDICAL CENTER
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on the review of medical records, documentation and interviews with hospital staff, it was determined that in one of one record (#8) the hospital failed to ensure the complete and accurate documentation was contained within the record of a patient who sustained a fall .
Review of record #8 revealed that the patient collapsed onto the floor from a bedside commode and staff initiated cardiopulmonary resuscitation.
An interview conducted on 4/20/2011 at 1320 hours with the Nurse Manager revealed a staff debriefing was conducted two days after the fall. During the debriefing a CNA revealed that he/she assisted the patient onto a bedside commode and failed to document that assistance.
Review of record #8 on 4/19/2011 at 1620 hours lacked documentation reflecting the assistance provided by the CNA.