HospitalInspections.org

Based on document review and interview, the Registered Nurse failed to follow the P&P (Policy & Procedure) related to fall prevention- post fall events - evaluation, for documentation -"circumstances", and P&P related to Medical Records for "complete" and "accurate" entries, in the patient's EMR (Electronic Medical Record), for 3 of 5 closed MR's (Medical Records) reviewed (Patient # 6, Patient # 7 and Patient # 8).

Findings include:

1. Review of established hospital policy titled: "Fall Prevention", indicated on page 8., under VI. "PROCEDURE FOR RESPONDING TO PATIENT FALLS": Guidance "Upon discovering a patient fall, the following will be completed and documented in the patient's medical record:", line 6. "Documentation of circumstances in the medical record". Policy last revised on 12/14/2018.

2. Review of established hospital policy titled: "Content of the Medical Record", indicated on page 1., under PROCEDURE, A., "All medical record entries, including handwritten and electronic", must be "complete" and "accurate", and on page 2., E. "Any observations relevant to care, treatment and services". Policy last revised on 1/26/2018.

3. Review of fall event logs for IMCU (Intermediate Care Unit) - 2nd floor for May through June 2019, indicated the following:
A. A fall event for Patient # 6 (Room 2106), on 5/5/2019 at "7:10 pm"; "unobserved/found on floor", "bruising".
B. A fall event for Patient # 7 (Room 2109), on 5/7/2019 at "11:05 pm", "injuries: Fx (fracture)/Dislocation".
C. A fall/"slip" for Patient # 8 (Room 2118), on 6/23/2019 at "1:40 pm", "Fall from chair", "Contusion", family member "at bedside".

4. Review of Patient # 6, # 7 and # 8 MR's, indicated the following:
A. Patient # 6, noted to have a fall on 5/5/2019 (as above). The MR lacked any documentation by nursing staff on 5/5/2019 pm, in regards to the actual fall event-description of how the patient was found and additional actions thereafter (i.e. patient returned to bed; patient sent for diagnostics).
B. Patient # 7, noted to have a fall on 5/7/2019 (as above). The MR lacked any documentation by nursing on 5/7/2019 pm, in regards to the actual fall event-description of how patient was found and additional actions thereafter (i.e. patient returned to bed, immobilize neck, patient sent for diagnostics, patient prepared for transfer to AH # 2 (Acute Care Facility/Hospital), report (nursing) called to AH # 2, patient transported to AH # 2 on 5/8/2019 am).
C. Patient # 8, noted to have "slip/fall" on 6/23/2019 (as above). The MR lacked any documentation by nursing on 6/23/2109 pm, in regards to the actual slip/fall event-description of how the patient was found and additional actions thereafter (i.e. patient return to bed and/or chair).

5. In interview on 8/26/2019 at approximately 1:35 pm, and approximately 1:38 pm, with A # 4 (Director- IMCU) and A # 8 (Manager-IMCU), and on 8/27/2019 at approximately 9:53 am, and approximately 2:00 pm, with A # 4, the following was confirmed:
A. That the electronic medical records for Patients # 6, # 7, and # 8, all lacked specific nursing documentation for the events of the patient's falls.
B. That the nursing staff is to include nursing narrative documentation for patient events.
C. 8/27/2019; after review of EMR's for Patients # 6, # 7 and # 8, that no nursing narrative documentation found for the events/circumstances.

6. In interview on 8/27/2019 at approximately 9:35 am, and at approximately 2:05 pm, with A # 1 (Director Risk Management) and A # 2 (Chief Quality Officer), the following was confirmed:
A. That nursing staff is educated in nursing orientation on required documentation in a patient's MR for events; such as for falls.
B. That nursing is good on completing an event report in the "ERS" (Electronic report system), but are lacking in documentation for the patient's medical record.
C. It was noted in the follow through on the event reports (specifically for Patient # 7), that nursing documentation of circumstances for the patient fall was not found in the patient's EMR. Nursing documentation was "not complete".

7. In interview on 8/27/2019, at approximately 9:55 am, and at approximately 12:10 pm, with A # 3 (Chief Nursing Officer), the following was confirmed:
A. That MR documentation by nursing in the patient's EMR, lacked description of events that occurred.
B. Nursing staff not following P&P's.