HospitalInspections.org

Based on medical record review, observation and staff interview it was determined the registered nurse failed to supervise and evaluate the nursing care related to fall precautions, assessments and providing assistance with activities of daily living for four (#2, #3, #6, #9) of ten patients sampled.

Findings include:

1. Patient #2 was admitted on 5/11/2014. Review of the nursing assessment dated 5/12/2014 revealed the patient was identified to be at risk for falls. Nursing documentation noted interventions in place included a yellow bracelet on the patient and yellow foot symbol on the patient's door.

Observation of the patient on 5/12/2014 at approximately 11:30 a.m. revealed no evidence of a yellow bracelet and no evidence of a yellow foot on the patient's door. The patient's nurse confirmed the finding at the time of the observation.


2. Patient #3 was admitted on 5/4/2014. Review of the nursing assessment dated 5/12/2014 revealed the patient was identified to be at risk for falls. Nursing documentation noted interventions in place included a yellow bracelet on the patient and yellow foot symbol on the patient's door.

Observation of the patient on 5/12/2014 at approximately 12:00 p.m. revealed no evidence of a yellow bracelet and no evidence of a yellow foot on the patient's door. The risk manager confirmed the finding at the time of the observation.

3. Patient #6 was admitted on 4/5/2014. Review of the nursing documentation revealed on 4/8/2014 at 2:35 a.m. the patient sustained a fall in his room. Review of the nursing assessment revealed no evidence of any pain or injury. Documentation revealed a right hip x-ray was ordered at 3:30 a.m. The results at 6:21 a.m. revealed a right hip fracture. Review of the record revealed no nursing documentation between 3:00 a.m. and 8:00 a.m. on 4/8/2014. There was no evidence of nursing reassessment during the stated time frame.

Interview with the risk manager on 5/12/2014 at approximately 3:00 p.m. confirmed the findings.

4. Patient #9 was admitted on 4/29/2014. Review of the nursing admission assessment revealed the patient had altered mental status, weakness and required assistance with ADLs (Activities of Daily Living). Review of nursing documentation dated 4/30/2014 revealed no evidence of any assistance provided with ADLs. Review of the nursing documentation on 5/3/2014 and 5/5/2014 revealed no evidence of assistance provided with ADLs.

Interview with the risk manager on 5/12/2014 at approximately 3:30 p.m. confirmed the findings.

Based on medical record review, review of policy and procedure and staff interview it was determined the facility failed to ensure nursing staff developed a nursing care plan for one (#6) of ten patients sampled.

Findings include:

Patient #6 was admitted on 4/05/2014. Review of the record revealed the patient was identified to be at risk for falls, had pain in the lower extremities, and an extensive medical history. Review of the nursing documentation revealed no evidence nursing developed a nursing care plan for the patient until 4/8/2014, three days after admission.

Review of the facility policy "Assessment-Reassessment", last revised 1/2012, stated the information generated through the analysis of assessment data is integrated to identify and prioritize the interventions of the interdisciplinary plan of care.

Interview with the Risk Manager on 4/13/2014 at approximately 10:00 a.m. confirmed there was no evidence a nursing plan of care was developed and initiated prior to 4/8/2014.