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INDIANA UNIVERSITY HEALTH
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, nursing services failed to complete fall risk shift assessments in 6 of 10 (Patients 2, 4, 6, 7, 8, and 9) medical records reviewed.
Findings include:
1. Facility policy titled, Fall Prevention, published 10/17/2023, indicated under VI. Procedures, Assessment, A. Fall Risk assessment should be completed: b. Once per shift.
2. Review of Patient 2's medical record lacked documentation of fall risk shift assessments on 02/03/2024 night shift and 02/04/2024 day shift.
3. Review of Patient 4's medical record lacked documentation of fall risk shift assessments on 03/23/2024 night shift, 03/24/2024 day shift, and 03/24/2024 night shift.
4. Review of Patient 6's medical record lacked documentation of a fall risk shift assessment on 03/27/2024 night shift.
5. Review of Patient 7's medical record lacked documentation of fall risk shift assessments on 04/15/2024 night shift, 04/19/2024 day shift, 04/21/2024 day shift, and 04/22/2024 night shift.
6. Review of Patient 8's medical record lacked documentation of fall risk shift assessments on 04/10/2024 night shift, 04/11/2024 night shift, 04/26/2024 day shift, 04/26/2024 night shift, 04/27/2024 day shift, 04/27/2024 night shift, 04/28/2024 day shift, 04/28/2024 night shift, 05/10/2024 day shift, 05/11/2024 day shift, 05/14/2024 day shift, and 05/16/2024 night shift.
7. Review of Patient 9's medical record lacked documentation of fall risk shift assessments on 05/07/2024 day shift, 05/11/2024 day shift, and 05/12/2024 night shift.
8. Interview with A3, (Clinical Nurse Specialist), on 07/31/2024 at approximately 4:55 p.m. confirmed Patients 2, 4, 6, 7, 8, and 9's medical record lacked documentation of fall risk assessments as indicated above.