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Based on review of documentation and interview with staff, the facility failed to document that a registered nurse supervised and evaluated the nursing care for 1 of 1 patient whose record was reviewed. Patient #1 was determined to be at a high risk for falls; however, the nursing staff did not ensure there was documentation of hourly rounds for fall prevention in the patient's medical record per facility policy.

Findings were:

Facility policy 1.4, entitled Fall Risk Assessment, last approved in April 2011, was reviewed. According to the policy, all patients are assessed for risk of falling when they are admitted and once per shift, or change in the patient's condition. The policy designates three levels of fall risk, and lists interventions appropriate for each level. The highest risk level is Level III. If a patient's risk score is 9 or above, he or she falls into this level. Included in the fall prevention interventions for Level III is the requirement, "All patients with a Fall Risk level of III should have a minimum of every one hour rounding checks assigned and documented."

The RN admission procedure includes the determination of a fall risk score. On 6/17/11, Patient #1 was evaluated and had a fall risk score of 11 (on a scale of 0.0 - 30.0). According to the fall prevention policy, the patient was considered a Level III, and the requirement was that the patient's status should be checked hourly and documented. The facility's electronic medical record allows a section to be utilized, entitled Safety/Quick Rounds. This section allows documentation regarding the evaluation of the safety precautions for patients, including those with risk of falls. These evaluations were not documented hourly for Patient #1. For example, rounds were documented on 6/17/11 at 00:24 am. The next safety rounds were documented at 2:55 am. Nursing staff documented in narrative notes Patient #1's non-compliance with safety instructions between 4:30 am and 5:47 am, along with an unwitnessed fall. No injuries were noted as a result of the fall. At 6:14 am, the Safety/Quick Rounds documentation indicated that Patient #1 was in bed and all safety precautions were in place. Safety/Quick Rounds were not documented again until 8 am and 10 am on 6/17/2012. The patient was discharged that day.

An in-person interview was conducted 2/21/12 at 5 pm in a facility conference room with the facility's Chief Nursing Officer (CNO). The CNO indicated that each patient is seen hourly by nursing staff, and this is documented on an hourly rounding sheet that is on the patient's door. It includes aspects of care such as toileting needs, pain, and safety. According to the CNO, these forms are kept by a nursing supervisor for a month then thrown away. No hourly rounding sheet was available to determine if Patient #1 was monitored according to the fall prevention policy.

Based on review of documentation and interview with staff, the facility failed to document that a registered nurse supervised and evaluated the nursing care for 1 of 1 patient whose record was reviewed. Patient #1 was determined to be at a high risk for falls; however, the nursing staff did not ensure there was documentation of hourly rounds for fall prevention in the patient's medical record per facility policy.

Findings were:

Facility policy 1.4, entitled Fall Risk Assessment, last approved in April 2011, was reviewed. According to the policy, all patients are assessed for risk of falling when they are admitted and once per shift, or change in the patient's condition. The policy designates three levels of fall risk, and lists interventions appropriate for each level. The highest risk level is Level III. If a patient's risk score is 9 or above, he or she falls into this level. Included in the fall prevention interventions for Level III is the requirement, "All patients with a Fall Risk level of III should have a minimum of every one hour rounding checks assigned and documented."

The RN admission procedure includes the determination of a fall risk score. On 6/17/11, Patient #1 was evaluated and had a fall risk score of 11 (on a scale of 0.0 - 30.0). According to the fall prevention policy, the patient was considered a Level III, and the requirement was that the patient's status should be checked hourly and documented. The facility's electronic medical record allows a section to be utilized, entitled Safety/Quick Rounds. This section allows documentation regarding the evaluation of the safety precautions for patients, including those with risk of falls. These evaluations were not documented hourly for Patient #1. For example, rounds were documented on 6/17/11 at 00:24 am. The next safety rounds were documented at 2:55 am. Nursing staff documented in narrative notes Patient #1's non-compliance with safety instructions between 4:30 am and 5:47 am, along with an unwitnessed fall. No injuries were noted as a result of the fall. At 6:14 am, the Safety/Quick Rounds documentation indicated that Patient #1 was in bed and all safety precautions were in place. Safety/Quick Rounds were not documented again until 8 am and 10 am on 6/17/2012. The patient was discharged that day.

An in-person interview was conducted 2/21/12 at 5 pm in a facility conference room with the facility's Chief Nursing Officer (CNO). The CNO indicated that each patient is seen hourly by nursing staff, and this is documented on an hourly rounding sheet that is on the patient's door. It includes aspects of care such as toileting needs, pain, and safety. According to the CNO, these forms are kept by a nursing supervisor for a month then thrown away. No hourly rounding sheet was available to determine if Patient #1 was monitored according to the fall prevention policy.