HospitalInspections.org

Based on interview and record review Nursing notes failed to ensure 1 of 5 medical records (ID# 1) clearly documented a patients complaint of pain after a fall.

Findings include:

Medical record review of patient ID# 1's nursing notes dated 3/7/10 at 3:55 a.m. stated "patient found on floor........complains of pain in his left knee and left hip." Physician orders on 3/7/10 at 5:40 a.m. ordered an x-ray of patient ID# 1's left shoulder. The nursing notes failed to document why an x-ray of the left shoulder was taken after the patient fell. Nursing pain assessments on 3/7/10 at 9:27 p.m. and 3/8/10 at 6:19 p.m. documented the patient was experiencing a pain rating of "8." The nursing assessment failed to describe where the patient was experiencing pain.

The Hospitals Risk Manager (ID# 50) acknowledged 6/11/10 at 1:00 p.m. that the nursing notes for patient ID# 1 did not document why an x-ray of the left shoulder was ordered or document where the patient was experiencing pain after a fall on 3/7/10. The Risk Manager further stated that the patient care nurse for patient ID# 1 failed to complete a variance report once the patient fell.

Record review of a policy titled "Falls Prevention Program" dated 5/14/2008 stated "Post Falls Interventions: Assess patient for trauma / injury........complete appropriate documentation of the fall in the medical record....."

Interview 6/14/10 at 8 a.m. with patient care nurse ID# 54 revealed she was caring for patient ID# 1 when he had a fall on 3/7/10 at 3:55 a.m. The nurse explained that she failed to document the patient's complaint of pain in his left shoulder after the fall because "it was towards the end of her shift."