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Based on interview and record review, the facility failed to ensure that nursing staff developed, and kept a current nursing care plan for one of 21 sampled patients (Patient 5), who was assessed as a high risk for falls on admission. This failure had the potential for the patient not to receive the appropriate assistance with mobility.

Findings:

On 10/6/15, the record for Patient 5 was reviewed. The patient was admitted to the facility on 10/2/15, with diagnoses that included pyelonephritis (Inflammation of the kidney) and sepsis (infection).

Review of the Fall Risk Assessment dated 10/2/15, indicated the patient scored at 7 and above which indicates a high risk for falls.

There was no current plan of care located in the patient's record that addressed Patient 5's high risk for falls.

On 10/5/15, at 3 PM, the Assistant Manager (AM) for the Medical Surgical Unit was interviewed. The AM agreed, the patient's high risk for falls should have been addressed in the patient's plan of care .

On 10/7/15, review of the facility Policy: C-109, effective date March 2013, titled, "Multi-Disciplinary Plan of Care," indicated, ..."b. A RN and/or a qualified individual from a discipline is responsible for:

1. Identifying expected outcomes individualized to the patient.
2. Developing a plan of care that prescribes interventions to attain expected outcomes..."