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Based on record review and interview the facility failed to ensure patients had a Registered Nurse (RN) assessment during a 24 hour period;

The facility failed to document on patients's records that they fell in the facility;

The facility failed to enforce its Nursing Assessment/Reassessment of Patient policy and their fall documentation policy. Citing six ( 6) sampled patients #s 1,2,3,4,5 and 6.

Findings:

Patient # 1

Review of a complaint narrative revealed information Patient (# 1) fell in her room at the hospital on 4/4/12 and also fell out of bed on 4/7/12 and fractured her ankle.

Review of nurses ' notes for Patient (# 1) revealed the following information:

Nurses notes dated 4/8/12 at 19:15 revealed documentation that Patient (# 1) was sent to Hospital NC for a stat CT scan post fall last night. There was documentation that the patient left the hospital at 11:20 and returned at 13:00.

Review of the patient ' s nurse ' s notes dated 4/4/12 through 4/7/12 revealed there was no documentation that the patient fell on both occasions. No documentation that the patient was evaluated and treated.

Nursing assessment and care dated 4/6/12 was completed on the seven (7) am to 7 pm shift by a Licensed Vocational Nurse(LVN) . There was documentation on 4/6/12 that the patient ' s care was handed over to another Licensed Vocational Nurse for the 7pm - 7 am shift. There was no documentation that that a Registered Nurse evaluated the patient's nursing care during the twenty four (24) period.

Patient #s 2 and 3

Review of nursing notes dated 4/1/12 revealed Patient #s 2 and 3 were assigned to the care of a Licensed Vocational Nurse for twenty four (24) hours with no evidence of intervention by a Registered Nurse.

Patient #s 4 and 5

Review of nursing notes dated 4/4/12 revealed Patient # 4 and 5 were assigned to the care of a Licensed Vocational Nurse for twenty four hours with no evidence of intervention by a Registered Nurse.

Review of daily staff assignment revealed both Licensed Vocational Nurses were assigned the care of the patients on their twelve hour shifts.

Review of the facility ' s Assessment/Reassessment of Patient policy revised November 2011 revealed the following information:

" All patients to whom nursing care is delivered shall be assessed/reassessed by a Registered Nurse once every 24 hours. The Registered Nurse is accountable for:
Accuracy, thoroughness, timeliness, of the assessment. "

During an interview on 4/12/12 at 2:20 pm with the Chief Nursing Officer she stated all patients should be assessed by the registered nurse within a twenty four hour period per the facility ' s policy. She further stated all patient occurrences must be documented in the patient's clinical record.

Patient # 6

Review of patient fall reports revealed data that Patient (# 6) fell on 4/6/12 and sustained a laceration on his right eye brow. There was no documentation on the patient ' s clinical record that the patient fell and was evaluated and treated.

Review of the facility ' s Post Fall Assessment Policy dated 10/6/11 Section B documented the following information:

" Following the post - fall assessment and any immediate measures to protect the patient an incident report should be completed.
A note should be entered into the patient ' s record including the results of the post fall assessment " .