HospitalInspections.org

Based on record review and interview it was determined the facility's Governing Body failed to ensure that the requirements of approved hospital policies were enforced.

Findings included:

The facility based policy "Patient Falls" stated in part,
" ...Procedure
...Post-Fall Management
When a patient falls:
1. Assess the patient for injuries, and if applicable, consider taking orthostatic vital signs.
2. Provide appropriate stabilization care and actions.
3. Notify the responsible provider that a Fall occurred and document notification in the medical record. As appropriate, notify the patient family. In addition, notify the charge nurse, unit supervisor, manager or house supervisor.
4. Document a post-Fall assessment and relevant clinical data in the medical record (e.g., Fall Event Note, Post Fall Assessment)."

2 out of 6 patient records did not include evidence or documentation a post fall assessment had occurred.