HospitalInspections.org

Based on a review of documentation and interviews, the facilty failed to ensure that all patient medical record entries were complete, as evidence by failing to document a patient fall according to facility policy.

Findings included:

Facility based policy entitled, "Patient Falls" stated in part,
"Post-Fall Management

When a patient Falls: ...

3. Conduct an updated fall risk assessment, consider taking orthostatic vital signs if not previously assessed, and implement all applicable interventions.
4. Notify the responsible provider that a Fall occurred and document notification in the medical record. As appropriate, notify patient family. In addition, notify the charge nurse, unit supervisor, manager, or house supervisor. Document a post-Fall assessment and relevant clinical data in the medical record (e.g., Fall Event. Note, Post Fall Assessment) ..."

Review of the medical record for Patient #1 revealed this patient sustained a fall at the facility on 02/15/23.
* There was no updated Fall Risk Assessment completed for Patient #1 after the fall on 02/15/23 occurred at 1500. The Fall Risk Assessment for this patient was not updated until 02/15/23 at 2000, this fall risk assessment also did not reflect a "Fall during this hospital admission".
* There was no Post-Fall assessment, or Fall Event note entered for this patient, beyond narrative notes documented by an operating nurse and the surgeon on the date of the fall 02/15/23.

In interview on 06/21/23, both staff member #1 and 3 verified that operating room staff cannot access these fall related notes in the electronic record, other areas such as inpatient and ICU nurses can access these notes. Due to being unable to access the following forms: Fall Risk Assessment, Post-Fall assessment, or Fall Event notes, the OR staff was unable to document Patient #1's fall appropriately per faciliyt policy.

The above findings were verified with staff members #1 and 3 on 06/21/23.