HospitalInspections.org

Based on Medical record and interviews the facility failed to have nursing notes and other necessary information present in medical record to monitor patient's condition in 1 ( Patient # 9 second admission) of 9 patients reviewed. :

Findings :

Patient # 9 ( second Admission ) on 08/01/2013 for post craniotomy with evacuation of hematoma that was performed at another facility and patient # 9 was readmitted 08/01/2013 to this facility. Review of the demographic history was under patient history with a fall risk of 75.

Review of Patient care policy/procedure for patient fall prevention protocol, Policy number 73, code F. states on page 1 under policy 1. The patient fall prevention protocol is applicable to hospitalized patients. Assessments includes use of modified Morse Fall scale for evaluation of potential fall risk and includes. A. History of falling: immediate or within 6 months ( Patient # 9 had a fall on the previous admission in July 2013 ) or F. mental status. ( Patient # 9 patient currently confused).

Review of policy/procedure for patient assessment and reassessment : Nursing Division , policy number 138-C, code A. Under purpose states that to ensure that all patients receive the appropriate assessment ( including initial/screening and reassessment) provided by qualified individuals within the organizational setting.
Under Policy numbered : 2. At the time of admission, each patient will be seen by the assigned nurse for evaluation of immediate needs.
Under policy numbered : 4. All patients will have an initial comprehensive assessment completed by a registered nurse. includes fall risk and data necessary to assess needs of the patient.
Under policy numbered : 5. As appropriate assessment , determined by the RN ( Registered Nurse) performing the initial assessment , and / or as indicated by initial physician order, other disciplines will be contacted to assess the patient.
Under policy numbered : 9. data collected on initial assessment shall be recorded into the nursing assessment record, and shall be available to all those disciplines involved in the care of the patient.
Under policy numbered: 11. Admission time frame for the Neurology- Telemetry Unit ( NTU) is to be initiated with in 30 minutes of arrival to the floor and completed with in 12 hours.

Review of initial assessment for patient # 9 second admission was not completed with in the 12 hours specified in the Policy numbered 138-C, Code A. as above shows. ( No initial nursing assessment was ever completed for patient # 9 second admission )
There is no documentation of second fall on the second admission in the nursing notes.

On 08/06/2013 at 10:06 AM an interview with staff # A bedside nurse at 10:06 has sitter at bedside due to falls. Had fallen twice in the facility, after the first admission had fallen and sent to another facility for evaluation. On return to this facility had a second fall. There should be a fall sign on the door and now there is a sitter at all times with patient. Patient is also with in site of nurses station.