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Based on interviews, chart reviews and policy review, the facility failed to fully assess Patient #1 beyond the fall assessment. This failed effort required the return of Patient #1 to complete the necessary assessments and treatment. The findings are:

A. Review of the medical record for the first, early morning visit on 07/08/14 revealed no evidence of assessments beyond the fall assessment and potential effects of the fall. No fluids were given, no assessment of the urinary status was recorded, no medications were documented and no documentation beyond the orders to obtain Computed Tomographies (CTs) of the head and two views of the pelvis. The notes to this first visit to the emergency room offered no explanation of Patient #1's elevated temperature or confusion.

B. On 07/28/14 at 3:25 pm, during interview, the Chief Nursing Officer verified that during Patient #1's first visit, the hospital staff was more focused on the potential injury from his fall instead of what could have caused the fall.

Based on medical chart review and staff interviews the facility failed to complete transfer documents for 3 (#2, 3, and 4) of 10 sampled patients. These failures resulted in potential harm to the patients from receiving facilities that were possibly unprepared to receive transfer of the patients. The findings are:

A. Review of the facility transfer document for Patient #2 revealed no nurse signature, no consent by the patient for transfer, no notation of who participated (and when) in what should have been a transfer report by phone between a nurse at the transferring hospital and a nurse at the receiving hospital, and no sign-off by the transport service accepting care of the patient.

B. Review of the facility transfer documents for Patient #3 and Patient #4 revealed no nurse signature, no notation of who participated (and when) in what should have been a transfer report by phone between a nurse at the transferring hospital and a nurse at the receiving hospital, and no sign-off by the transport service accepting care of the patient.

C. On 07/28/14 at 1:30 pm during interview the acting Chief Nursing Officer and Chief Quality Officer/Risk Management Director confirmed the above missing documentation.