HospitalInspections.org

Based on record review and interview, the facility staff failed to document notification of a physician and other appropriate care team members after a change in condition (fall) for 1 of 3 patients with falls (Patient #1) in a total of 10 medical records reviewed.

Findings Include:

A review of the facility's policy titled, "Assessment and Reassessment" (no last revision date) revealed, "... Data collected shall be recorded in the nursing assessment record and shall be available to all those disciplines involved in the care of the patient..."

A review of Patient #1's medical record revealed Patient #1 was an 81-year-old who was admitted to the facility from 08/29/2024 through 09/03/2024 for respite care. Patient #1 was receiving home hospice services at the time of the hospital admission. A review of the nursing note documented in Patient #1's medical record on 09/02/2024 at 6:46 AM revealed, "At 0520 (5:20 AM), pt had a fall and nursing staff responded immediately to find pt lying on the floor on her right side. Pt stated she did not hit her head, but her right hip was painful... Provider notified, no
interventions at this time." There was no evidence found in the medical record of documentation regarding notification of the telehealth provider or hospice, and no documentation regarding the outcome of those communications.

During an interview on 10/29/2024 at 1:41 PM with Nurse Manager C, when asked about Patient #1, Nurse Manager C stated, "Staff contacted the provider using the Avel system (telehealth provider) after the fall occurred. The charge nurse contacted hospice and notified them of the patient's fall."

During an interview on 10/30/2024 at 9:27 AM with Charge RN (Registered Nurse) K, when asked about if there was documentation in the medical record regarding contact with the [telehealth] provider or hospice after Patient #1's fall, Charge RN K stated, "It should be detailed in my note."