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Based on policy and procedure review and medical record review, the registered nurse failed to supervise and evaluate the nursing care for each patient related to documenting patients as a fall risk or that fall precautions were in place, and not updating the treatment plan for 3 of 4 (patients #1, 2, and 3) closed patient medical records reviewed and 2 of 6 (patients #5 and 8) open patient medical records reviewed of patients who were a fall risk; not appropriately screening patients on admission or after a change in functional status or a newly identified risk such as a fall, to determine if rehabilitation evaluation is needed related to physical therapy for 3 of 4 (patients #1, 2, and 3) closed patient medical records reviewed and 2 of 6 (patients #5 and 8) open patient medical records reviewed; and not completing an Incident Report immediately when an incident occurs for 1 of 2 (patient #2) closed patient medical records reviewed of patients who sustained a fall.

Findings:

1. Policy #II-A.9, Fall Risk Identification and Precautions, revised/reapproved 10/2014, indicated on pg. 1 and 2, "All patients presenting for admission will be assessed and identified for fall risk...Fall precautions will be documented on the patients Q15 minute observation form...The nurse shall initiate a Treatment Plan and update as necessary."

2. Policy #II-E.21, Therapy Screening, revised/reapproved 10/2014, indicated on pg. 1, "All new admissions, without therapy orders, will be screened upon admission...to determine if rehabilitation evaluation is appropriate...Patients who experience a change in functional status or a newly identified risk situation should be screened by therapy if an evaluation has not been initiated...Status change may be identified through...falls report."

3. Policy #III-B.11, Incident Reports, revised/reapproved 10/2014, indicated on pg. 1, "an Incident Report should be completed immediately when an incident occurs."

4. Review of closed and open patient medical records on 4/20/15 at approximately 1300 hours, confirmed:
A. patient #1:
a. was a fall risk according to fall risk score from admission 2/3/15 to discharge 3/2/15, but the Patient Observation Monitoring Rounds form was blank for fall precautions on 2/4/15, 2/5/15, and 2/6/15. The Total Fall Risk Score was also not totaled up on the Daily Nursing Record on 2/6/15 and 3/2/15. Medical Progress Notes and Neurology Service Daily Progress Notes confirmed patient's gait was unsteady and at times in wheelchair on 2/5/15 and 2/9/15.
b. had cognitive decline and "states that he/she has a tremendous decline in his/her ability to balance during ambulation." The Admission Database also confirms "allows extremities to be moved without resistence...laying motionless in bed with the bed alarm armed." Did not have physical therapy orders upon admission and was not screened for therapy on admission. Physical therapy was not ordered for this patient.

B. patient #2:
a. was a fall risk according to fall risk score from admission 1/30/15 to discharge 3/6/15, but the Patient Observation Monitoring Rounds form was blank for fall precautions on 2/4/15, 2/5/15, 2/6/15, 2/27/15, and 2/28/15. The Master Treatment Plan confirms patient was a fall risk on admission and during stay. Sustained a fall with wrist injury on 2/27/15.
b. Daily Nursing Record confirmed patient had unsteady gait with poor balance. Did not have physical therapy orders upon admission and was not screened for therapy on admission. Physical therapy was not ordered for this patient until two days before discharge on 3/4/15.

C. patient #3:
a. was a fall risk according to fall risk score from admission 2/25/15 to discharge 4/3/15, but the Patient Observation Monitoring Rounds form was blank for fall precautions on 2/27/15 and 2/28/15. The Master Treatment Plan confirms patient was a fall risk on admission and during stay. Sustained a fall with head injury on 2/26/15.
b. was admitted with delusional disorder and possible neurologic event such as seizure or stroke. Did not have physical therapy orders upon admission and was not screened for therapy on admission. Physical therapy was not ordered for this patient.

D. patient #5:
a. was a fall risk according to fall risk score from admission 4/13/15 to 4/20/15, but the Patient Observation Monitoring Rounds form was blank for fall precautions on 4/14/15, 4/15/15, and 4/16/15. The Master Treatment Plan confirms patient was a fall risk on admission and during stay.
b. did not have physical therapy orders upon admission and was not screened for therapy on admission. Physical therapy was not ordered for this patient.

E. patient #8:
a. was a fall riskaccording to fall risk score from admission 4/3/15 to 4/20/15, but the Patient Observation Monitoring Rounds form was blank for fall precautions on 4/7/15 and 4/8/15. The Master Treatment Plan confirms patient was a fall risk on admission and during stay.
b. did not have physical therapy orders upon admission and was not screened for therapy on admission. Physical therapy was not ordered for this patient.

Based on policy and procedure review and medical record review, the facility failed to ensure all patient medical record entries were complete related to the priority status of radiology orders and specific time frame for orders 2 of 2 (patient #2 and 3) closed patient medical records reviewed of patients requiring an order for radiology services.

Findings:

1. Policy #II-G.16, Radiology Ordering Procedure, revised/reapproved 10/2014, indicated on pg. 1, "The physician responsible for ordering a diagnostic radiology procedure shall include the following in the written or verbal order...priority status of STAT, ASAP [as soon as possible], or routine)."

2. Policy #II-C.52, Noting Physician Orders, revised/reapproved 2/2015, indicated on pg. 1, orders will have a "time frame specific to how long that order is to be followed."

3. Review of closed patient medical records on 4/20/15 at approximately 1300 hours, confirmed:
A. patient #2 had an x-ray of the wrist ordered on 2/27/15 at approximately 1750 hours and the order lacked the priority status of STAT, ASAP, or routine.
B. patient #3 had a CT (computed tomography) scan of brain without contrast ordered on:
a. 2/26/15 at approximately 1750 hours and the order lacked the priority status of STAT, ASAP, or routine.
b. 2/28/15 at approximately 1432 and the order lacked the priority status of STAT, ASAP, or routine.