HospitalInspections.org

Based on record review and interview, the facility failed to ensure that the nursing staff develops, and keeps current, a nursing care plan based on assessing patient needs and developing appropriate nursing interventions in response to those needs for 3 of 5 sampled patients (#2, 4 & 5).

Findings:

1. Patient #4's record reflected a very high risk for falls on 07/30/10 at 7:30 p.m. but failed to document the application of bed alarm or the hourly bed checks on that shift. The record also failed to document bed checks on the day shift on 08/01/10.

2. Patient #5 record reflected a very high risk for falls on 07/30/10 at 10 p.m. but failed to document the application of bed alarm or the hourly bed checks on that shift.

3. Patient #2's record reflected a very high risk for falls on 04/14/10 at 8:10 p.m. but failed to document an hourly bed check on day shift 04/15/10 prior to the fall. Interview with the Nurse Manager at 3:30 p.m. reflected that the nurse caring for the patient had checked the patient about 10 minutes prior to finding the patient on the floor at 1:45 p.m. on 04/15/10.

Review of facility policies reflected that they were consistent with current standards of care a regulations.

Interview with risk manager and the director of nursing on 08/02/10 at 4:30 p.m. confirmed the findings.

Based on record review and interview, the facility failed to ensure that the nursing staff develops, and keeps current, a nursing care plan based on assessing patient needs and developing appropriate nursing interventions in response to those needs for 3 of 5 sampled patients (#2, 4 & 5).

Findings:

1. Patient #4's record reflected a very high risk for falls on 07/30/10 at 7:30 p.m. but failed to document the application of bed alarm or the hourly bed checks on that shift. The record also failed to document bed checks on the day shift on 08/01/10.

2. Patient #5 record reflected a very high risk for falls on 07/30/10 at 10 p.m. but failed to document the application of bed alarm or the hourly bed checks on that shift.

3. Patient #2's record reflected a very high risk for falls on 04/14/10 at 8:10 p.m. but failed to document an hourly bed check on day shift 04/15/10 prior to the fall. Interview with the Nurse Manager at 3:30 p.m. reflected that the nurse caring for the patient had checked the patient about 10 minutes prior to finding the patient on the floor at 1:45 p.m. on 04/15/10.

Review of facility policies reflected that they were consistent with current standards of care a regulations.

Interview with risk manager and the director of nursing on 08/02/10 at 4:30 p.m. confirmed the findings.