HospitalInspections.org

Based on document review and interview, nursing services failed to document Morse Fall Risk Score assessment upon admission in 5 of 10 (patients 4, 5, 6, 9, and 10) medical records reviewed and failed to document the nurse's review of the fall risk predictive score on the fall risk assessment in 6 of 10 (patients 2, 3, 6, 8, 9, and 10) medical records reviewed.

Findings include:

1. Facility policy titled, Fall Precautions Procedure, PolicyStat ID 17599893, last revised on 07/23/2025, indicated under Risk Assessment: The nurse will assess and/or review fall risk and document interventions at the following times: A. Within four (4) hours of arrival/admission., B. Once per shift with a minimum of twice in a calendar day.

2. Review of patient 2's medical record indicated the following:
a. The patient was admitted on 08/15/2025.
b. Medical record lacked documentation of the nurse's review of the fall risk predictive score on the fall risk assessment on 08/16/2025 night shift and on 08/17/2025 day shift.
c. The patient was discharged on 08/18/2025.

3. Review of Patient 3's medical record indicated the following:
a. The patient was admitted on 07/29/2025.
b. Medical record lacked documentation of the nurse's review of the fall risk predictive score on the fall risk assessment on 08/01/2025 night shift, and on 08/03/2025 day shift and night shift.
c. The patient was discharged on 08/06/2025.

4. Review of patient 4's medical record indicated the following:
a. The patient was admitted on 07/29/2025.
b. Medical record lacked documentation of the Morse Fall Risk Score assessment upon admission.
c. The patient was discharged on 07/31/2025.

5. Review of patient 5's medical record indicated the following:
a. The patient was admitted on 07/26/2025.
b. Medical record lacked documentation of the Morse Fall Risk Score assessment upon admission.
c. The patient was discharged on 08/05/2025.

6. Review of patient 6's medical record indicated the following:
a. The patient was admitted on 07/24/2025.
b. Medical record lacked documentation of the Morse Fall Risk Score assessment upon admission.
c. Medical record lacked documentation of the nurse's review of the fall risk predictive score on the fall risk assessment on 07/24/2025 night shift, and on 07/25/2025 day shift and night shift.
d. The patient was discharged on 07/26/2025.

7. Review of patient 8's medical record indicated the following:
a. The patient was admitted on 07/31/2025.
b. Medical record lacked documentation of the nurse's review of the fall risk predictive score on the fall risk assessment on 08/02/2025 day shift, on 08/10/2025 day shift, on 08/11/2025 day shift, and on 08/12/2025 day shift and night shift.
c. The patient is a current patient.

8. Review of patient 9's medical record indicated the following:
a. The patient was admitted on 07/26/2025.
b. Medical record lacked documentation of the Morse Fall Risk Score assessment upon admission.
c. Medical record lacked documentation of the nurse's review of the fall risk predictive score on the fall risk assessment on 07/29/2025 day shift.
d. The patient was discharged on 07/31/2025.

9 Review of patient 10's medical record indicated the following:
a. The patient was admitted on 07/26/2025.
b. Medical record lacked documentation of the Morse Fall Risk Score assessment upon admission.
c. Medical record lacked documentation of the nurse's review of the fall risk predictive score on the fall risk assessment on 07/27/2025 day shift, on 07/29/2025 day shift, and on 08/02/2025 day shift.
d. The patient was discharged on 08/04/2025.

10. Interview with A2 (Accreditation Specialist) on 08/18/2025 at approximately 6:00 p.m. confirmed the following:
a. The nursing fall education indicated inpatient nursing completes the Morse Fall Risk Score for patients within 4 hours of admission.
b. Patients 4, 5, 6, 9, and 10's medical records lacked documentation of the Morse Fall Risk Score upon admission.
c. Patients 2, 3, 4, 5, 6, 8, 9, and 10's Medical record lacked documentation of the nurse's review of the fall risk predictive score on the fall risk assessment.