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Based on record review and interviews the facility failed to maintain the clinical record / Electronic Health Record (EHR) content with 1 of 12 sampled patients (Patient 3) who sustained a fall resulting with the right hip fracture.

Findings include:

During a record review concurrent with an interview on 5/1/2019 at 10:00 a.m., with Staff #2 she acknowledged that Patient 3 was admitted on 2/27/19 with diagnosis of Acute Cerebrovascular Accident, Left Middle Cerebral Artery, Posterior Cerebral Artery Infarct and history of Lupus. In addition Staff #2 confirmed that there were no evidence that the nurse documented the fall incident in the nursing notes and a post fall risk assessment was implemented. Also she states that the nursing notes does not have any evidence of how the fall was adequately monitored. Prior fall assessment for Patient 3 documented that the Morse Fall score was 50, which placed the patient on a high risk for fall. According to the adverse event report on 3/14/19 Patient 3 fell in her room as a result sustained a right hip fracture. The nurses failed to document the adverse event in the nurse notes per hospital policy.

During an interview on 5/1/2019 at 12:00 p.m., with Staff #1 she indicated that she had made rounds 2 times in the beginning of the evening shift on 3/14/19 and did not witnessed Patient # 3 fall in the room. When asked if she received report at the beginning of her shift that Patient #3 was a risk for fall she indicated "No".

Reviewed the policy Titled "Fall Prevention Program" approved on 1/30/19 it reveals that:
- A plan of care will be implemented based on the risk assessment score.
- Communicate high risk status during report and patient transfers.
- Document in the notes:
Physician notification
Medical and nursing actions that were taken
Level of injury with descriptions
Location of fall
Observations of patients appearance at the time they were discovered
Patient response to the fall such as altered mental status
Presence of pain.

- All falls will be documented and reported in the EHR.

Based on observation, interview and record review the hospital failed to ensure all post anesthesia care evaluations were completed in accordance with the hospital policy. Failure to complete post anesthesia care notes in accordance with standards of practice and hospital policy may lead to failures to identify potentially negative adverse effects associated with the administration of anesthesia.

Findings include.

The recently revised Pre and Post Anesthesia Evaluation Policy states "All patients receiving general, regional or monitored anesthesia shall have a post anesthesia evaluation completed and documented by a practitioner qualified to administer anesthesia, as stated above, no later than 48-hours after surgery or a procedure requiring anesthesia services."
"The calculation of the 48-hour timeframe shall begin at the point the patient is moved into the designated recovery area. Except in cases where postoperative sedation is necessary for the optimum medical care of the patient (i.e., ICU) the evaluation generally would NOT be performed immediately at the point of movement from the operative area to the designated recovery area."

1. Sample patient 8 is a 64 year old male who was admitted in to the Post Anesthesia Care Unit (PACU) on 04/29/2019 at 08:45 status post amputation (removal) of the right 5th toe due to gangrene. On that same date his records were reviewed with Staff Registered Nurse 24. Staff 24 acknowledged Sample 8 had been admitted into the PACU at 08:45 and that his Post Anesthesia Care Note was written already written, signed and timed for 08:45 (the admission time). The patient was discharged from the PACU at 10:15.

2. Sample patient 9 is a 14 year old male what was admitted into the PACU on 04/29/2019 at 08:55 status post tonsillectomy and adenoidectomy related to chronic tonsillitis and tonsillar hypertrophy. On that same dated his records were reviewed at 09:43 with Staff Registered Nurse 25. Staff 25 acknowledged patient 9's records reflected the patient was stable and that his post anesthesia note had been timed as being written at 09:45. That is, the record reflected the note was written and timed even before being admitted into the recovery room. The patient was discharged from the PACU at 10:25 and transferred to the Pediatric Unit.