NHS Lanarkshire must improve the time taken to assess elderly patients at Wishaw General Hospital.
The warning follows a visit by Health Improvement Scotland which found “poor” examples of record-keeping.
Inspectors said there was “good leadership” in wards while patients and visitors “spoke positively about the care given”.
However, the report stated: “We found older patients weren’t always accurately assessed within the national standard recommended timeframes, a lack of person-centred care plans and concerns around the completion of the assessment of capacity to consent and staff understanding of adults with incapacity.
“It is important to stress that poor documentation does not automatically mean care is poor. We cannot say care was poor, only that we could not be assured that care was safe and appropriate.”
Senior inspector Ian Smith added: “NHS Lanarkshire must ensure all older people are assessed within the national standard timescales. This includes frailty, bedrails, nutritional assessment and screening, falls and pressure ulcers. We will continue to monitor the situation.”
NHS Lanarkshire’s Frances Dodd said that since the visit in March work is taking place to ensure a range of clinical assessments and resultant care plans are done timeously.
She was pleased that a “change in culture from target-driven to more safety-driven” had been recognised.