HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the nursing staff completed the admission history and basic admission information within 24 hours of admission and performed a timely fall risk scale for one of four sampled patients (Patient 2) as per the hospital's P&P when Patient 2 was admitted to the step-down level of care. This failure had the potential to result in substandard care for the patient.

Findings:

Review of the hospital's P&P titled Assessment, Reassessment, and Data Collection dated 1/18/24, showed the following:

1. Admission History and Basic Admission Information
a. Initiated when accepting a newly admitted patient.
b. Collected within two hours for all admitted patients.
c. Completed within 24 hours of admission including at a minimum:
i. Language & interpreter needs
ii. General information
iii. Medication history & compliance
iv. Allergies
v. Transfusion history
vi. Nutrition
vii. Malnutrition screening tool (MST)
viii. Social history
ix. Domestic violence screening
x. Psychosocial stressors
xi. Advance directive
xii. Discharge needs
xiii. Suicide screening
xiv. Initial infectious screening
xv. Immunization screening
xvi. Basic admission information

2. Baseline/Initial Assessment: head-to-toe physical assessment based on age, condition, diagnosis, and care setting.
a. Initiated when accepting a newly admitted patient.
b. Collected and documented within two hours for all admitted patients.
c. Subsequent head-to-toe physical assessment shall be performed for all admitted patients at a minimum of once per shift within the first two hours of the beginning of the assigned shift.
d. Including at a minimum.... "fall risk scale"

On 8/6/25 at 1013 hours, the Adult ED was toured with the Nursing Quality Director and Nurse Manager 1. During the tour RN 1 was interviewed. RN 1 stated she was assigned to be a charge nurse today. RN 1 stated patients who were boarding in ED after the admission order, received the level of care as the physician's order.

On 8/6/25, Patient 2's medical record was reviewed with the Nursing Quality Director and Clinical Nursing Director. Patient 2's medical record showed Patient 2 arrived at the ED on 8/4/25.

Review of the physician's order dated 8/5/25 at 0542 hours, showed to admit Patient 2 to step-down level of care.

1. On 8/6/25 at 1127 hours, an interview and concurrent medical record review was conducted with the Clinical Nursing Director in the presence of the Nursing Quality Director. The Clinical Nursing Director stated the elements of the admission assessment and initial assessment were already initiated during ED stay. The documented assessment could be found in different ED documentation forms. During the concurrent medical record review with the Clinical Nursing Director and Nursing Quality Director, not all the elements of the General Information were documented. The following elements were not able to be found in Patient 2's medical record:

* Sensory changes
* Patient/Caregiver instructed to only take prescribed hospital medications while hospitalized
* Patient desires family or patient representative to be notified on admission
* Transfusion history
* Malnutrition screening tool
* Psychosocial stressors
* Advance directive

2. Review of Patient 2's medical record titled Adult Systems Assessment dated 8/6/25 at 0600 hours, showed Patient 2's initial head-to-toe assessment was performed after the admission order. Further review of Patient 2's medical record showed the fall risk score was performed on 8/6/25 at 1900 hours (13 hours later).

On 8/6/25 at 1415 hours, the Nursing Quality Director, Clinical Nursing Director, and Assistant Hospital Administrator verified the above findings.