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Based on observation, interview, and record review, the facility failed to ensure a registered nurse (RN) assessed patient needs per facility policy. R.N. Admission fall risk assessments were incomplete or incorrect for 7 of 8 current patients ( Patient IDs # 2, 3, 5, 6, 7, 8, 9).

Findings include:


Observation and record review on 06-28-17 between 9:30 a.m. and 11:00 a.m. on the Meadows Unit revealed a patient census of 22.

Record review of the "Nursing Admission Assessment ( Part ll) : Falls Assessment " for eight (8) current patient medical records revealed the following:

Patients # 5, #12: had a large illegible word written across the entire falls assessment section. Interview at the time of record review with Director of Nurses (DON) # 53, he was unable to decipher the words and said this was not an acceptable practice.

Patient # 9: had the word "refused" written across the falls assessment section.

Patient # 3: incomplete fall risk assessment; scored incorrectly.

Patient # 7: incomplete fall risk assessment; not scored.

Patient # 6: falls assessment was scored correctly; however, the following interventions were checked as "yes": "patient given precaution arm band" & "star placed on room door & medical record." Observation of Patient # 6's arm and room door failed to support these interventions had been put in place.

Patient # 8: incomplete fall risk assessment; multiple blank areas; no total score. The following interventions were checked as "yes": "patient given precaution arm band" & "star placed on room door & medical record." Observation of Patient # 8's arm and room door failed to support these interventions had been put in place.

Further review of the "Falls Assessment" section of the nursing admission form read : " *A total of 10 pr more indicates a risk for falling and must be an ACTIVE ( facility capitalization) problem on the treatment plan." Record review of the eight current patient records revealed 6 of 8 did not have a documented total fall risk score.

Interview with DON # 53 on 06-28-17 at 11:45 a.m. , he stated the fall assessments were not properly completed and staff training was needed.

Record review of facility policy titled" Assessment-Fall", revised date 08/2016, read: "PURPOSE: To alert multidisciplinary team members of the risk of fall and to minimize the patient from falling during treatment. To provide appropriate intervention for patients that are potential fall risks and to provide a safe environment. ..PROCEDURE 1. An initial screen for Fall Precautions Form will be completed on all patients upon admission on the nursing assessment. 2. Patients that are identified as fall risk will be identified in the following ways: 1. yellow identification armband clip 2. yellow stickers stating 'fall risk' on front of patient's medical record..."