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ADVENTHEALTH SEBRING 4200 SUN N LAKE BLVD SEBRING, FL 33872 May 13, 2015
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on medical record review, staff interview and review of policy and procedure it was determined the registered nurse failed to evaluate and supervise care for one (#3) of ten patients sampled related to falls.

Findings include:

Review of the facility policy "Assessment & Reassessment of Patients", last reviewed 5/2013, stated reassessment of the patient will also be performed following an adverse incident and/or change in the patient condition.

Patient #3's nursing documentation dated 4/02/2015 at 12:03 a.m. revealed the RN (Registered Nurse) documented the patient was found on the floor in the room and bleeding. Review of the record revealed there was no documentation of the patient's complaints following the fall, no documentation of the location of the bleeding, and no documentation of the intervention or treatment for the bleeding. Documentation revealed the physician was notified and an x-ray of the knee and CT scan of the head was ordered and completed. Review of the nursing assessments revealed no evidence the patient was reassessed timely post-fall.

Review of the physician's assistant's progress notes dated 4/02/2015 at 9:24 a.m. noted the patient sustained a fall and hit her head and knee. Review of the progress notes revealed the patient complained of neck pain upon evaluation. Review of the physician orders dated 4/02/2015 revealed an order for a CT scan of the cervical spine. Results of the CT scan of the cervical spine revealed the patient sustained a C2 fracture with displacement.

Review of the record revealed no evidence the patient was reassessed by the RN following the patient fall and no evidence of the location of the bleeding or any treatment provided.

Interview with the risk manager on 5/12/2015 at approximately 12:15 p.m. confirmed the above findings.