The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

CAPE CORAL HOSPITAL 636 DEL PRADO BLVD CAPE CORAL, FL 33990 Feb. 19, 2014
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on interview and record review, the facility failed to ensure that the medical record for 1 of 10 patients (#1) contained the timely results of a nursing assessment.

The findings include:

On 12/6/13, at 8:00 a.m.; Patient #1 reported that he fell to his nurse. Review of the record show that no entry was made on 12/6/13, regarding the patient's report. Interview with the nurse on 2/11/14, at 2:08 p.m.; revealed that she informed the cardiologist at approximately 1:00 a.m. and also reported it to the hospitalist. The nurse stated that she assessed the patient after the report; however, she failed to document the assessment at that time.
On 12/9/13, the nurse made a late entry documenting that the patient reported a fall. Documentation of the patient's report was not timely and available to other practitioners for review on 12/6/13.