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NW INDIANA-AMG SPECIALTY HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, nursing failed to assess a patient after a fall in 1 (Pt4) of 2 medical records.
Findings Include:
1. Review of policy titled: Fall Prevention and Management Program last revised 6/20, indicated that a post fall assessment is to be completed and to include vital signs, neuro checks and level of injury.
2. Review of Patient 4's medical record lacked post-fall documentation of vital signs, neuro checks and level of injury on the Post-Huddle Facilitation Guide.
3. Interview on 08/18/20 at 3:40 pm confirmed that the Post-Fall Huddle Facilitation Guide lacked documentation of vital signs, neuro checks and level of injury post fall.