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Based on clinical record review, family and staff interview, the hospital failed to ensure nursing staff performed an inclusive assessment for 1 (Patient #4) of 10 patients sampled.

The findings include:

Record review, on 10/18/11, for sampled Patient #4 document the patient was admitted to the hospital, on 7/29/11 and discharged home on 8/4/11. The patient had diagnoses that include, but are not limited to, a Urinary Tract Infection, Dehydration, Acute Renal Failure, and Chronic Lymphocytic Leukemia.

The nursing progress notes, for 7/31/11, at 0337, document Patient #4 was found on floor. Nursing progress note shows no limitations in Range Of Motion (ROM); however, the 7/31/11 shift assessment done after 8:00 a.m. shows limited ROM in all four extremities. No further assessment documentation is recorded as performed by the nurse on 7/31/11 at 3:37 a.m. Documentation of a Physical Therapy evaluation, on 8/3/11, document a scab is noted on her left knee, but the nursing assessments do not document a scab.

Interview with family reporting Patient #4 sustained two falls while hospitalized. A review of the patient's clinical record, on 10/18/11, only one fall is documented.

Interview with the nurse manager, on 10/18/11, at 4:00 p.m., reveals she completed a facility report for the Patient #4 being found on the floor, at noon on 7/30/11. She stated the physician assistant was on the unit, was notified, and saw the patient approximately 45 minutes later.

Review of the clinical record reveals the incident of the fall and a nursing assessment post fall is not documented. Per the nurse manager, an agency nurse was working that day and did not document the fall or an assessment in the record.

Patient #4 was found on the floor twice during her hospitalization. Nursing staff failed to document that the patient was assessed completely for injuries post fall.