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Based on medical record review, document review and interview, the facility did not ensure a safe environment for Patient #2, who was identified as being at risk for fall. Failure to implement fall prevention measures in a timely manner has the potential for patient harm.

Findings include:

Review on 08/24/16 of policy " Comprehensive Fall Guideline- NS.320 " revealed that for patients entering triage a falls assessment screen is performed. Once the patient enters the Emergency Department (ED) standard precautions, which include double grip socks/appropriate footwear, are applied for each patient.

Review of ED Nursing Transfer note dated 07/31/16 at 6:37 PM revealed the patient had been assessed as being at risk for falls.

Review on 08/24/16 of Facility Incident report dated 08/01/16 revealed the patient sustained a fall following admission to the inpatient unit after being left unattended in the bathroom without double grip socks/appropriate footwear in place.

Interview with Staff #3 on 8/24/16 verified these findings.

Based on medical record review, document review and interview the medical record contained incomplete physician documentation in 1 of 9 Emergency Department ED records (Patient #3). This has the potential to result in a lack of continuity of care.

Findings include:

Interview with Staff # 30 on 08/26/16 revealed the patient had a methicillin resistant staph aureus infected sacral decubitus that was being treated.

Review of the Physician ED "T-form" dated 07/01/16 revealed the review of systems did not include the presence of paraplegia and multiple decubitus ulcers and the physical exam noted the patient's skin as being intact despite the presence of right heel, left lower leg and sacral decubiti.

Review of Medical Staff policy and procedure MS004 titled "Medical Records" revealed medical records are to be prepared and completed in a timely manner and that any incomplete portions of the record must be completed no later than 19 days after the record becomes available.