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TEXAS HEALTH HARRIS METHODIST FORT WORTH
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on record review and interview, the hospital failed to provide patients with care in a safe setting, in that, 2 of 10 patients (Patient #3 and #7) had a fall that was not documented in the medical record with the patient's condition, the doctor notification, and the family notification after the fall.
Findings Included:
According to an interview with the surveyor on 07/14/14 at 1:00 PM, the Nurse Manager (Personnel #5) stated the nurse had found Patient #3 on "the floor." There was no documentation in Patient #3's medical record after the fall that included the patient's condition, the physician's notification, or family notification by the staff.
The Discharge Summary for Patient #7 documented that Patient #7 had an "...admission complicated by unwitnessed fall. Patient was found down on the floor by nursing..." No date was indicated for the fall. There was no documentation in Patient #7's medical record of the patient's condition, the physician's notification, or family notification by the staff regarding the fall directly after Patient #7's fall.
During an interview with Staff #3, #4 and #5, on 7/14/2014 at 11:00 in the Conference room, they stated that there is no policy that documents what the nurse's responsibility is to follow after a fall.
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on record review and interview, the hospital failed to meet the needs of 2 of 10 patients (Patient #3 and Patient #7), in that, Patient #3 and Patient #7 fell during their inpatient hospital stay. There was no documentation of an evaluation of Patient #3 and Patient #7 after the fall by the RN (Registered Nurse).
Findings included:
According to an interview with the surveyor on 07/14/14 at 1:00 PM, the Nurse Manager (Personnel #5) stated the nurse had found Patient #3 on "the floor." There was no documentation in Patient #3's medical record that included an evaluation/assessment by the RN after a fall.
The Discharge Summary for Patient #7 documented that Patient #7 had an "...admission complicated by unwitnessed fall. Patient was found down on the floor by nursing..." There was no documentation in Patient #7's medical record that included an evaluation/assessment by the RN directly after a fall.
During an interview with Staff #3 and #5 on 7/14/2014 at 2:00 PM in the Conference Room, the surveyor asked if they could show where an RN documented an assessment after the fall in the medical record of Patient #3 and Patient #7. They answered " No. "