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KALEIDA HEALTH
NURSING CARE PLAN
Tag No.: A0396
Based on medical record review, document review and interview, nursing staff did not ensure that a care plan was developed to meet the care needs of Patient #21 (1 of 20 medical records). Specifically, the protocol for falls precautions was not implemented after the nursing assessment for falls risk. Failure to follow protocols places patients at risk of not receiving needed interventions for patient safety.
Findings include:
Review of Nursing Falls Information documentation dated 08/17/16 at 01:15 PM revealed a Morse Fall Risk Score of 50.
Review of policy/protocol entitled "Adult Fall Prevention" last revised on 03/14/16 revealed a Morse Fall Scale of 45 or greater requires a patient to be put on falls precaution.
Review of physician order dated 08/17/16 at 03:24 PM revealed order to place Patient #21 on falls precautions.
Interview with Staff #24 on 10/20/16 at 01:40 PM verified the physician order and need for the initiation of the falls protocol.