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Based on interview and record review, the facility failed to ensure that nursing staff developed and kept current a care plan with accurate fall risk assessments for 1 of 5 sampled patients. (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted on 8/19/09. A nursing assessment of 8/20/09 at 1 AM using the Morse fall scale revealed the patient to be at a high risk for falls. The scoring in this assessment indicated a history of a fall within 3 months. The total score was 75. The assessment indicated the implementation of safety precautions. A nursing assessment of 8/20/09 at 8 PM using the Morse fall scale revealed the patient to be at a low risk for falls. The scoring in this assessment indicated no history of falls within 3 months. The total score was 50. A nursing assessment of 8/21/09 at 8 PM using the Morse fall scale also revealed the patient to be at a low risk for falls. The scoring in this assessment indicated no history of falls within 3 months. The total score was 50.

The fall history item was the only difference between the above assessments. Since a history cannot change, one entry or the other (having a fall history or no fall history) was inaccurate.

During an interview with the Nurse Manager of the Surgical Intensive Care Unit, on 8/06/10 at 1:30 PM, she confirmed the above findings.