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Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to update the patient's plan of care to include identified fall risks for 2 (#1, #2) of 5 (#1, #2, #3, #4, #5) sampled patients reviewed for falls.

Findings:

Patient #1
Review of Patient #1's medical record revealed he had been admitted on 1/21/18 with a diagnosis of sepsis. Review of the admission nursing assessment revealed a fall risk assessment score of 45 (25 for a history of falls and 20 for IV/Saline lock). The risk level was assigned at moderate risk (score of 25-44) which required further education to the patient by the staff. The score of 45 should have scored Patient #1 as a high risk.

Review of Patient #1's medical record revealed on 1/23/18 he was determined to be a high fall risk which required education, fall risk sign above bed, yellow gown, yellow non-skid socks, and a yellow armband.

Review of Patient #1's nursing care plan revealed no problem identified with interventions listed for fall risk.

Review of an incident report for Patient #1 dated 1/23/18 revealed at 6:40 p.m. he was sitting at the nurses' station in locked wheelchair on 1:1 supervision. Patient attempted to get up after numerous instructions not to attempt without assistance due to high fall risk. Patient fell attempting to ambulate without assistance. Patient hit head on corner of desk. Patient sustained 3.5 cm x 0.5 cm laceration to left lateral scalp. At 7:15 p.m. he had 5 staples placed into his scalp.

In an interview on 4/9/18 at 3:10 p.m. with S4RN Director, she verified fall risk should have been identified as a problem on Patient #1's care plan but had not been identified.

Patient #2
Review of the medical record for Patient #2 revealed he had been admitted on 1/9/18 with diagnosis of shortness of breath. Review of Patient #2's nurses' admission Fall Screening revealed he was scored as 35 which placed the patient as a moderate risk.

Review of Patient #2's nursing care plan revealed no problem identified with interventions listed for fall risk.

Review of an incident report for Patient #2 revealed on 1/11/18 at 4:40 a.m. a family member had called for assistance. Patient #2 was found lying on bathroom floor after unwitnessed fall. His Oxygen saturation was 67% on room air. After placing Patient #2 on oxygen the saturations were increased to 99%. A laceration was noted to his right hand. Respiratory was notified to get extension tubing so Patient #2 could ambulate without having to remove his oxygen.

In an interview on 4/9/18 at 4:00 p.m. with S5RN, she verified the above mentioned medical records did not have problems identified for being a fall risk.

Patient#4
Review of Patient #4's medical record revealed an admit date of 3/7/18 with the diagnoses of chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Patient #4 was discharged 3/12/18.

Review of Patient #4's nursing admission Falls Screening assessment dated 3/7/18 revealed the patient was a High Risk for falls.

Review of Patient #4's nursing comprehensive care plan dated 3/8/18 at 12:30 a.m. revealed no problem identified with interventions listed for fall risk.

Review of an incident report for Patient #4 revealed patient had a fall with an injury on 3/11/18 at 1:05 a.m. Patient got up to use restroom. Respiratory therapist, heard bang in bathroom. Patient had a small half-inch laceration to the left elbow.

Review of Patient #4's nursing comprehensive care plan dated 3/11/18 at 8:14 a.m. revealed no problem identified with interventions listed for fall risk after patient sustained a fall with injury.

Review of Patient #4's nursing comprehensive care plan dated 3/12/18 at 3:43 a.m. revealed no problem identified with interventions listed for fall risk after patient sustained a fall with injury.

During an interview on 4/10/18 at 9:00 a.m. S6RN acknowledged Patient #4's chart had no problem identified with interventions listed for fall risk.