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Based on interview and review the hospital failed to ensure physicians had assessed patients' status of two of three sampled patients who had fallen in accordance with hospital policy (Patient 18 and 19). This failure resulted in incomplete post fall evaluations to detect patient injuries.

Findings:

1. Review of Patient 18's record indicated the patient fell on 12/8/24 around 7 p.m. and on 1/1/25 at 2:30 p.m.

During an interview on 3/7/25 at 10 a.m., the practice advisor (PA) who reviewed the record stated she did not find physician or practitioner documentation specific to evaluating the patient's post fall status and stated physicians needed to be notified.

2. Review of Patient 19's nurses note on 1/12/25 at 10:27 p.m. indicated the patient was found down in a sitting position. The same nurses note indicated at 11:59 p.m., a physician acknowledged reading a message that the patient fell.

During an interview on 3/7/25 at 10:45 a.m., the PA who reviewed the record stated there was no post fall physician assessment.

Review of the Fall Assessment, Prevention, and Management procedure, dated March 2023, under the management of patient falls indicated provider was to assess the patient within one hour post fall if no injury detected.

Based on interview and record review the hospital failed to ensure registered nurses timely identified a patient's scalp pressure injury (localized damange to the kin and/or soft tissue, often over a bony area) and documented a patient's falls (Patient 18) for two of 30 sampled patients (Patients 5 and 18).

The failure of the late pressure injury assessment led to a delay in treatment.
The failure of the incomplete fall documentation had the potential for not implementing pertinent fall preventative measures.

Findings:

1. Review of Patient 5's Pressure Injury Care Consult Note, dated 2/3/25 at 12:27 p.m., indicated the patient was able to self reposition and transfer out of bed.

Patient 5's Pressure Injury Care Consult Note, dated 2/5/25 at 4:10 p.m., indicated the patient acquired an unstageable pressure injury (full thickness skin and tissue loss with inability to determine the extent of damage due to dead tissue covering the wound) on his occiput (back of head) that was painful. One of the recommendations from the same note indicated to perform full head to toe assessment each shift (every 8 or 12 hours). There was no prior head to toe nursing documentation indicating Patient 5 had a developing occipital wound.

During an interview on 3/6/25 at 10:32 a.m., the wound nurse (WN) who reviewed the record, WN stated Patient 5's occipital wound was first identified on 2/5/25, the wound was hard to identify because the patient had thick hair, and the wound should have been found earlier.

Review of the Pressure Injury and Wound Care Assessment and Management policy, dated January 2025, it indicated clinical nurses were to assess the wound each shift and to document.

2. Review of Patient 18's record indicated the patient fell on 12/8/24 around 7 p.m. and on 1/1/25 at 2:30 p.m. There was no documentation in the nurses notes about the falls (the circumstances, potential causes, patient or witness statements).

During an interview on 3/7/25 at 10 a.m., the Practice Advisor (PA) who reviewed the record stated she did not find nursing documentation addressing Patient 18's falls.

Review of the Fall Assessment, Prevention and Management procedure, dated March 2025, under management of patient falls, indicated to perform head to toe assessments and document the findings in the electronic health record.

Based on interview and record review the hospital failed to ensure a medical record was complete for one of 30 sampled patients (Patient 1). Patient 1's chest x-ray results was improperly labeled with the wrong patient's name and reviewed by a physician.

This faillure resulted in inaccurate interpretation of the patient's health status.

Findings:

During an interview on 3/10/25 at 2 p.m., the physician (PHY) stated she read another patient's x-ray that was incorrectly labeled as Patient 1. An hour later she reviewed the correct Patient 1's x-ray and reinformed Patient 1's family member of the result.

Review of Patient 1's Pulmonary Consult Note, dated 1/29/25 at 8:31 p.m., indicated there was an error of a wrong patient radiograph (chest x-ray) in the patient's folder.

A policy addressing the correct labeling of patient record was requested and staff was not able to find one on 3/10/25.