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Based on record review, and staff interview, 1 of 10 patients (pt #1), the Hospital failed to provide care to ensure the safety of the patient.

Findings include:

1. The physician of record was notified of a patient fall on 7/3/2025 in which the patient complained of knee pain following the fall. No assessment of the patient by a physician or advanced practice provider was completed following the fall and subsequent change in condition.

2. Following transfer of the patient from the hospital bed to a wheelchair, prior to discharge on 7/3/2025, the patient complained to the House Supervisor of new-onset ankle pain. The physician was not notified of the change in condition. No assessment of the patient by a physician or associated advanced practice provider was completed following the change in condition.

3. The Administrative Coordinator of Regulatory Compliance, E #1, and Associate Chief Nursing Officer, E #3, verbally agreed an assessment of the patient by a physician or associated Advanced Practice provider should have been completed following each occurrence.

Based on record review, document review, and staff interview for 1 of 10 patients (pt #1), the Hospital failed to supervise and evaluate the nursing care for each patient per Hospital policy.

Findings include:

1. During review of Pt #1's record, it was found that nursing staff failed to document a patient's change in condition post fall and following complaint by the patient of knee pain, ankle pain following transfer from the patient bed to a wheelchair, and notifying the facilities HART (High Acuity Response Team) nurse of a fall per the Falls Prevention: SAFE policy attachment "Blessing Hospital Post Fall Guideline & 48 Hour Post Fall Process."

2. Review of the Hospital's Falls Prevention: SAFE policy states, "Appendix: Blessing Hospital Post Fall Guidelines & 48 Hour Post Fall Process ...Immediate Post Fall Procedure ...If apparent injury-notify HART Nurse of patient fall and request review."

3. In an interview with the Administrative Coordinator-Regulatory Compliance, E #1, on 8/21/2025 at approximately 11:30 am, E #1 verbally agreed the HART Nurse should have been called, and was not called after a fall with apparent injury and a review was not completed.

A.) Based on record review, document review, and staff interview for 1 of 10 patients (Pt #1), the Hospital failed ensure the nursing care plan reflected the nursing care provided to meet the patient's needs per Hospital policy.

Findings include:

1. During record review it was found that nursing staff failed ensure the medical record reflects the nursing care provided per the Hospital's Discharge Planning policy as evidenced by the following:

a. No medical record entries were made to document a change in patient condition which had the potential to change the patient's discharge needs.

b. No Physician order was documented to indicate the patient was able to continue to discharge with current orders following the patient fall.

c. No Physician order was documented to indicate the need for evaluation of the patient after a change in the patient's condition.

2. Review of the Hospital's Discharge Planning Policy (Last approved 03/2025) states, "6. If at any other time during the patient's hospital stay, needs are identified by other members of the health care team, Inpatient Care Coordination staff are notified and the appropriate action is taken.

a. The patient's discharge plan is reassessed if there are changes that may affect continuing care needs or the appropriateness of the discharge plan."

3. During an interview with the Administrative Coordinator-Regulatory compliance, E #1, on 7/21/2025 at approximately 11:40 am, E #1 agreed the patient's discharge plan was not reassessed when there was a change in condition that may affect continuing care needs or the appropriateness of the discharge plan per hospital policy.


B.) Based on record review, document review and staff interview for 1 of 10 patients(pt #1), the Hospital failed ensure documentation of the nursing care provided was entered in a timely manner.

Findings include:

1. During record review it was found that nursing staff failed to document point of care/concurrent charting (real time) per the Hospital's Knowledge Based Documentation (02/2023) as evidenced by the following:

a. The nursing note dated and timed for 7/3/2025 at 12:10 (12:10pm) was entered on 7/3/2025 at 20:12 (8:12pm).
b. The nursing note dated and timed for 7/3/2025 at 14:45 (2:45pm) was entered on 7/3/2025 at 20:13 (8:13pm).
c. The nursing note dated and timed for 7/3/2025 at 15:15 (3:15pm) was entered on 7/3/2025 at 20:13 (8:13pm).
d. The nursing note dated and timed for 7/3/2025 at 17:29 (7:29pm) was entered on 7/3/2025 at 20:17 (8:17pm).
e. The nursing note dated and timed 7/3/2025 at 17:30 (7:30pm) was entered on 7/3/2025 at 20:17 (8:17pm).
f. The nursing noted dated and timed for 7/3/2025 at 17:30 (7:30pm) was entered on 7/3/2025 at 20:21 (8:21pm).

2. Review of the Hospital's Knowledge Based Documentation policy states, "Point of Care/Concurrent Charting (Real Time)-charting immediately or within one hour to two hours of the care rendered; intent is documentation at bedside, at time care is provided."

3. During an interview with the Administrative Coordinator-Regulatory compliance, E #1, on 7/21/2025 at approximately 11:40 am, E #1 verbally agreed that the nursing notes were not entered timely, per hospital policy.