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A. Based on a review of policy and procedure, medical record review, and staff interview, it was determined that in 1 of 10 (Pt #1) medical records reviewed, the CAH failed to ensure the interventions to prevent falls were always documented.

Findings include:

1. The CAH policy and procedure titled, "FALL RISK ASSESSMENT CRITERIA - RATER'S GUIDE" was reviewed. It indicated under, "HIGH FALL RISK - SCORE 4 OR ABOVE" the following interventions, "All low and moderate interventions AND Utilize an alarm system. Check and/or offer help q hour. Utilize gait belt when ambulating patient...."

2. The medical record of Pt #1 was reviewed on 8/1/11. It indicated Pt #1 presented to the ED on 5/2/11 with a complaint of post-fall with severe pain in head, neck, and right hip. Pt #1 was admitted and documentation of the fall risk assessments consistently rate her as a 6 or 7, which places her in the high risk category. (Examples: On 5/2/11 scored 6, on 5/4 scored 7, and on 5/5 scored 7). However, documentation throughout the medical record did not always reflect the use of a gait belt when ambulating/transferring the patient. Some examples include: 5/8/11 at 1545, "Up to Commode", 5/8/11 at 2331, "Up to Commode", 5/9/11 at 0450, "Up to Commode", 5/14/11 at 0800 Up to Commode, Recliner Chair". There was no documentation of the use of a gait belt during any of the aforementioned examples.

3. During an interview with the Director of Quality/Risk Management, conducted on 8/1/11 at 10:45, the above findings were confirmed.

B. Based on a review of policy and procedure, medical record review, and staff interview, it was determined that if 1 of 1 (Pt #1) medical records reviewed in which the patient received physical therapy (PT) services, the CAH failed to ensure the reasons for not providing care were always documented.

Findings include:

1. The CAH policy and procedure titled, "DOCUMENTATION FOR PHYSICAL THERAPY" was reviewed. It indicated under, "Special Issues The following guidelines are to be followed to insure complete and proper documentation of all patient related issues....1. Any cancellation on missed appointments will be documented and will include the reason for the missed treatment, if provided...."

2. The medical record of Pt #1 was reviewed on 8/1/11. It indicated that Pt #1 was admitted to the CAH on 5/2/11 with a diagnosis of fracture of right hip. Documentation indicated that once on 5/3/11, and twice on 5/4/11 the PT therapy visits were cancelled. There was no documentation that indicated the reason for the cancellation.

3. During an interview with the Director of Rehabilitation Services, conducted on 8/1/11 at 1:45 PM, the above findings were confirmed.