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Based on record review, review of facility policies, and staff interview it was determined the facility failed to ensure the Registered Nurse supervised and evaluated the nursing care for 1 (#1) of 4 patients sampled. This practice does not provide for safe quality nursing care.

Findings include:

Review of the policy, "Fall Prevention Plan of Care " , last revised 10/10, states post fall management the patient will be assessed for signs of injury, physician notified, conduct fall/injury assessment, notify supervisor, and notify family of fall. Documentation in nursing note should indicate the location of patient when found, the patients report of the fall, assessment of patient ' s condition, who was notified of the fall, fall risk assessment post fall, injury risk assessment, vital signs, post fall interventions, and patient and family education.

Patient #1's MAR (Medication Administration Record) dated 10/28/10 revealed the patient was medicated for chest pain with Dilaudid 1 mg (milligram) IV at 11:15 a.m. The scheduled pain medication, Oxycodone, 30 mg by mouth, was administered at 11:15 a.m. Review of the nursing documentation revealed the vital signs at 11:00 a.m. showed a blood pressure of 96/54. Review of the nursing note documented at 12:50 p.m. stated the patient tripped on a bedside table and fell to the ground. The patient complained of right hip pain, vital signs stable, and x-ray ordered. Physician order at 1:00 p.m. stated if x-ray negative, patient may be discharged home.

There was no documentation the physician was notified of the low blood pressure as documented at 11:00 a.m. as 96/54. There was no documentation of the patient's vital signs following the fall. The next blood pressure was documented at 3:00 p.m. as 84/47. There was no documentation the physician was notified of the low blood pressure

Interview with the unit nurse manager on 12/16/10 at 12:20 p.m. confirmed no documentation of the vital signs following the fall on 10/28/10 or physician notification of the blood pressures. The nurse manager confirmed the registered nurse failed to follow the facility's policy.

Based on staff interview and review of policy, procedure, and clinical records it was determined that the facility failed to ensure a safe discharge for one (#1) of four records reviewed related to assessing the patient prior to discharge for change in condition. This practice does not ensure post hospitalization goals are maintained.

Findings include:

Review of the facility's policy, "Reassessment" , last revised 6/06, states the patient will be reassessed just prior to discharge or transfer.

Patient #1 was admitted on 10/25/10 with a diagnosis of chest pain. Review of the nursing documentation revealed a nursing note on 10/28/10 at 11:40 a.m. stating discharge orders were noted. Review of the MAR (Medication Administration Record) revealed the patient was medicated for chest pain with Dilaudid 1 mg (milligram) Intravenous (IV) at 11:15 a.m. The patient's scheduled pain medication, Oxycodone 30 mg by mouth, was given at 11:15 a.m. The patient reported the pain as 7 out of 10 on a scale of 1-10 with 10 being the worst possible pain. Review of the nursing documentation revealed the patient's vital signs at 11:00 a.m. showed a blood pressure of 96/54. Review of the nursing note at 12:50 p.m. stated the patient tripped on a bedside table and fell to the ground. The patient complained of right hip pain, vital signs stable, and x-ray ordered. Physician order at 1:00 p.m. stated if x-ray negative, patient may be discharged home as previous orders stated.

Review of the hip x-ray revealed it was negative for any injury. There was no documentation the physician was notified of the patient's low blood pressure as documented at 11:00 a.m. as 96/54. There was no documentation of the patient's vital signs following the patient's fall. On 10/28/10 at 5:20 p.m. review of the nursing documentation revealed a note stating right hip x-ray completed and negative. Transportation was called and the patient left the floor in a wheelchair with family.

Review of the nursing assessments on 10/28 revealed the patient was reassessed at 8:00 a.m. and a nursing note at 12:50 p.m. stating the patient tripped and fell. The next nursing note at 5:20 p.m. indicated the patient was discharged and left the floor. Review of the patient's vital signs revealed the patient's blood pressure at 11:00 a.m. was 96/54. The next blood pressure was documented at 3:00 p.m. as 84/47. There was no documentation of a nursing intervention. There was no documentation the physician was notified of the patient's blood pressure prior to discharge.

Interview with the unit nurse manager on 12/16/10 at 12:20 p.m. confirmed no documentation of the patient's vital signs following the patient's fall on 10/28/10 and no documentation the physician was notified of the patient's blood pressure that was documented at 3:00 p.m. The unit nurse manager confirmed the patient was not reassessed just prior to discharge.