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QUALITY ASSURANCE

Tag No.: C0337

Based on interview and record review the CAH failed to monitor and evaluate patient care services and failed to identify opportunities for improvement of those services including; the failure to identify that patient care services were not provided in accordance with established policies and procedures regarding identifying patients with a high fall risk and implementing prevention interventions. Findings include:
Per interview with the facility ' s Chief Nursing Officer [CNO], the Quality Director, and the Nurse Manager on 5/20/14 at 12:04 P.M. the facility ' s policy and procedure for new admissions includes the admitting Nurse assessing the patient ' s risk of falls, and if assessed as a high risk, implementing hourly observations of the patient every day as a fall prevention tool. A list of high risk patients is then compiled, updated, and reviewed each morning with nursing staff. Per record review on 5/20/14, a sampling of patient fall risk lists and corresponding hourly rounding sheets from 4/29/14 through 5/7/14 were reviewed for completeness and accuracy with multiple errors noted. Per the record review and confirmed during interview with the CNO, Quality Director, and the Nurse Manager, 7 patients during the 9 days sampled were identified as high fall risks but the preventative hourly rounding was not done. 39 of 107 hourly rounding sheets contained blank hours with no documentation, and 8 rounding sheets had no date to indicate when they were done. Additionally, 6 times between 4/7/14 & 5/7/14 fall risk patients are identified not as fall risks but as patients with alterations in skin integrity.
Per interview with the CNO, Quality Director, and the Nurse Manager on 5/20/14, the CNO stated it was the Nurse Manger ' s responsibility to monitor the fall risk lists and hourly rounding reports. The Nurse Manager reported h/she was unaware that hourly rounding was not being done on the 7 patients identified as high fall risks, and if there were problems with any data the Charge Nurse was to report them to h/her. The CNO and Nurse Manager confirmed there was no process in place to review the data and identify errors from the hourly rounding sheets and fall risk lists. The CNO confirmed the documentation on both the fall risk lists and the hourly rounding sheets was ' inconsistent ' and stated ' we need to come up with a way ' of tracking and monitoring the data.