HospitalInspections.org

Based on interview, and record review, the hospital failed one of one patient (Patient #2) by not following not ensuring that medical records shall be accurately written.

Findings include;

Through interview the staff is a contracted nurse who is not at the facility at the time of the interview. The patient was 86 years of age at the time of the interview and it was verified in the interview that the patient was not 66-75 years of age. It was verified through interview that the record was not consisent with the patient's condition.

Through review of the medical records which reflected the following information not being accurate. This information was also shared with and verified by staff #2: "The hospital Psychiatric Falls Risk Assessment dated 01/29/19 at 1200 reflected the following information; "age 66-75, fall history 0, Ambulatory Aide; walker, unsteady shuffling ...Patient is a low falls risk, oriented to own ability, Patient education provided." The patient was 86 at the time of there were no noted falls while in the hospital, but is a high risk for falls. At intake she was noted as needing a walker to assist with ambulation.