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Based on interview and record review, the facility failed to ensure compliance with the delineated responsibilities for patient care, as stated in policy, for 1 of 10 sampled patients who required a full assessment prior to discharge (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted to the facility through the Emergency Room on 12/19/11. A nurse's note of 12/20/11 at 7:31 AM mentioned the presence of a pressure ulcer on the left buttock which was being treated with Mediplex. A nursing note of 12/24/11 indicated the presence of a pressure ulcer on the right buttock and that a dressing was in use.

A final nursing assessment was performed at 8 AM on 12/28/11. However, this did not include the two pressure sores, as mentioned above. The medical record had not indicated that the pressure sores had resolved by discharge. Thus, the assessment, which was a patient care responsibility, was not complete. The lack of a complete assessment was not in compliance with policy (see below).

A Case Management note of 12/28/11 at 10:33 AM read, "Call received from ... at Consulate (a skilled nursing facility) that bed is available today. Arrangements made for pt to be transported to (room number)." The patient was discharged at 11:48 AM.

A review of facility policy "2011 Plan for Assessment/Reassessment" revealed the following: "Patients in the Medical Surgical Units are reassessed, at a minimum, every 12 hours, with change in patient condition and prior to transfer or discharge."

The preceding was confirmed during an interview of the Quality Manager at approximately 4 PM.