HospitalInspections.org

Based on review of clinical records, hospital policies, and staff interviews, the hospital failed to ensure that a registered nurse properly supervised and evaluated the nursing care for each patient, as there was no documented evidence that patient was monitored with hourly rounding and there was no nursing documention of a fall, physican notification, or assessment of the patient post fall.
Findings were:
Review of facility policy, Nursing Assessment, Reassessment and Admission, stated, in part, " 5. Reassessment of the patient ' s needs may occur for many reasons including the following;
a. To evaluate the response to care, treatment, and services;
b. B. To respond to a significant change in status and/or diagnosis or condition;
c. C. To satisfy legal or regulatory requirements;
d. D. To meet the time intervals specified by the institution;
e. E. To reevaluate pain at subsequent intervals based on the patient ' s presenting needs.
6. Patient needs identified through the assessment and reassessment serve as the basis for an individual plan of care.
Review of facility policy, Nursing Documentation, stated, in part, " Reassessment is documented when the patient ' s level of care changes, at change of shift, and as the patient ' s condition warrants. "
Patient #1 sustained a fall in the evening on 07/13/12 according to physician documentation. Event Progress note completed by the DO, dated 7/13/12 at 2001, stated, " called to patient room after she sustained a falling (sic) while trying to get to restroom. She fell on her bottom, hitting the left bottom cheek. She did not loose (sic) consciousness or hit her head. Also complaining of some low back pain that has been worsening as the day progressed.
Exam: Hematoma to left bottom. No broken skin, no redness, Tender to palpation. Deep palpation to secondary tissue not tender. No active bleeding. Slight tender to palpation suprapubic."

Review of Patient #1's medical record revealed, nursing assessments performed every shift on 07/12/12 through 07/13/12 indicating that Patient # 1 was identified as a fall risk. The Fall Risk Assessment for both days included " hourly rounds " with " yes " indicated.
2 Pain Assessments were completed on 07/13/12 at 21:49 and 22:49 stating the patient reported pain to the sacrum.
According to nursing documentation, Patient #1 was transferred to the 5th floor on 07/13/12 at 2240. The Nursing Assessment performed upon transfer on 07/13/12 at 22:40, included the flowing integumentary notation " " Skin integrity- bruise-left gluteal " .
Nursing Note date 07/13/12 at 22:48 stated, " Patient temp 100.4. Notified Dr. Brackman and informed of temp. New order for Motrin 600 mg PO X 1 NOW. Order noted. Request a X-ray to bruised area on left gluteal r/t fall. Dr. Brackman stated not at this time due to injury is to soft tissue and not to coccyx or other bony primises (sic). No further orders at this time. "
A review of all nursing documentation for 07/13/12 and 07/14/12 revealed no documented description of the actual fall event which occurred on the evening of 07/13/12. There was no documented notification of the physician or physical assessment of the patient post fall.
In an interview with Staff member # 1, on 10/1012 at 1100, she stated that " hourly rounds " are currently included in the nursing assessment. The hourly rounds are not currently documented in the medical record, logged, or tracked by the facility.