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CAPE CORAL HOSPITAL
CONTENT OF RECORD
Tag No.: A0449
Based on interview and record review, the facility failed to ensure that the medical record for 1 of 10 patients (#1) contained the timely results of a nursing assessment.
The findings include:
On 12/6/13, at 8:00 a.m.; Patient #1 reported that he fell to his nurse. Review of the record show that no entry was made on 12/6/13, regarding the patient's report. Interview with the nurse on 2/11/14, at 2:08 p.m.; revealed that she informed the cardiologist at approximately 1:00 a.m. and also reported it to the hospitalist. The nurse stated that she assessed the patient after the report; however, she failed to document the assessment at that time.
On 12/9/13, the nurse made a late entry documenting that the patient reported a fall. Documentation of the patient's report was not timely and available to other practitioners for review on 12/6/13.