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Based on record review and interview, the hospital failed to ensure multidisciplinary assessments, nursing assessments, and nursing interventions were included and updated in patient treatment plans for one (Patient #4) of four patients..

This failed practice had the potential to increase the risk for inadequate assessment and planning, lengthened hospital stay and decreased quality of care.

Findings:
Staff I's Physical Therapy (PT) assessment, on 05/20/19 at 4:49 pm, showed Patient #4 had decreased awareness of the need for assistance, and required assistance in problem solving, and assistance with implementing safety solutions. The record did not show the PT assessment was incorporated into the fall risk assessment for Patient #4.

On 05/21/19 at 1:41 am, documentation showed the Hester-Davis fall assessment score was 15. On 05/29/19 at 10:00 am, Staff F stated the Hester-Davis fall score of 15 is a high fall risk.

The medical record showed, on 05/21/19 at 4:55 am, that Patient #4 was medicated for pain with Hydrocodone 20mg by mouth, there was no indication of the patient's response to the medication.

A document titled "Progress Notes", 05/21/19 at 6:50 am, showed Staff H did not discuss of the patient's fall risk status, and did not document the safe-room status of Patient #4, with the outgoing Registered Nurse.

A document titled "progress notes, 05/21/19, at 7:30 am, showed that Staff H answer Patient #4's call light and him/her on the floor; Staff J was attempting to return Patient #4 to bed. Staff H documented swelling and deformity to the lower left leg.

A document titled "Incident Report Log", from 06/01/18 through 05/28/19, showed that on 05/21/19 Patient #4 was assisted to the sit on the side of the bed, by Staff J. Staff J provided the patient supplies for a sponge bath and left the room. The document showed that no hospital staff members were in the room and Patient #4 fell off of the bed.

A document titled "Preoperative History & Physical" 05/23/19 states Patient #4 fell in the hospital room and experienced a left tibia fracture.

Document "Patient Fall Prevention (08/13/18)" showed fall risk assessments would be conducted on patients at admission, daily, and when there was a change in the patient's condition or level of care. The policy showed the patient's individual risk factors would be used to develop interventions to prevent falls; assessments would be documented on the Adult Assessment or the Hester-Davis Fall Risk sheet; staff would ensure Safe Room set-up to include, bed wheels locked, bed in low position, room free from clutter, clear path to bathroom, call light within reach, dry floor, non-slick foot wear, and call light within reach.

Document titled "Nursing Documentation Guidelines (05/23/19)" showed that documentation reflects the needs, problems, capabilities, and limitations of the patient, and reflect the patient's response to interventions.
Document titled "Routine Care- Activities of Daily Living (08/08/18)"stated that Activities of Daily Living (ADLS) include tasks that involve functional mobility such as dressing, bathing, toileting, personal care, and bathing; staff would assess the patient's ability to perform ADLS.

According the manufacture of hydrocodone, Allergan, https://www.allergan.com/assets/pdf/norco_pi, hydrocodone can produce Central Nervous System- Drowsiness, mental clouding, lethargy, impairment of mental and physical performance, anxiety, fear, dysphoria, psychological dependence, mood changes. , dizziness, drowsiness, fuzzy thinking, and light headedness.

In an interview conducted on 05/29/19 at 10:00 am Staff member G stated that Hester-Davis fall assessments are conducted on patients each shift and are adjusted dependent on the interventions, the patient's condition, and the patient's ability to care for themself.