HospitalInspections.org

Based on document review and interview, the facility failed to maintain an accurate medical record on 1 of 10 medical records (MR) reviewed (MR of P6).

Findings include:

1. Facility policy titled, Documentation, PolicyStat ID 13393218, last approved 04/23, indicated all incidents in patient care are to be charted, as they may cause a change in the patient's condition that requires treatment or observation and to enter all medications, treatments and other nursing tasks after the activity has been completed.

2. Facility policy titled, Event Reporting (ERS) Policy, PolicyStat ID 9858640, last approved 06/21, defined an adverse event/event as a happening or occurrence that is not part of the routine care of a particular patient or the routine operation of the healthcare entity. The policy indicated in section 4, Documentation, when an event involving a patient occurs, it is important to document only the facts regarding the occurrence and the medical record (MR) entry should be brief and exclusively limited to the most pertinent facts regarding the occurrence.

3. Facility policy titled, Fall Prevention, PolicyStat ID 9099224, last approved 01/21, defined a fall as an unplanned descent to the floor with or without injury, and an assisted fall as a staff member is present to ease the patient's descent or break the fall. This policy indicated, under Nursing Responsibility Post-Fall, to notify physician.

4. Review of MR for P6 indicated the following:
a. Physical Therapy Treatment Note, dated 9/6/23, indicated an assisted fall to the floor.
b. Interdisciplinary Note- Nursing, dated 9/9/23 for event time of 7:30 pm, indicated 2 nurses attempted to get P6 up to the bedside commode, patient was unable to bear weight and was returned to bed.
c. MR lacked documentation of an assisted fall to the floor occurring on 9/9/23 at approximately 7:30pm.
d. The notification box in the MR flowsheets lacked documentation of physician notification of assisted falls having occurred on 9/6/23 and 9/9/23. The notification box was not completed with required information such as date, time and who was notified.

5. Incident report dated 9/10/23 for event on 9/9/23 at 7:30 pm, indicated P6 had an assisted fall to the floor.

6. In interview on 12/14/23, at approximately 12:55 pm, A2 (Registered Nurse [RN], Administrator and Chief Nursing Officer [admin/CNO]) verified the interdisciplinary note, for 9/9/23 at 7:30 pm, did not describe a fall to the floor as described in the incident report.

7. In interview on 12/14/23, at approximately 1:30 pm, A1 (Director of Quality [DQ]), verified no physician notification was documented in the MR for 2 fall events experienced by P6.

8. In interview on 12/18/23, at approximately 9:20 am, N2 (RN) verified he/she was present for the assisted fall to the floor on 9/9/23 at 7:30 pm.