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Based on review of policies and procedures, medical record review and staff interview, it was determined the Hospital failed to ensure that five (5) of five (5) patients had:

1. a registered nurse (RN) co-signing licensed practical nurse (LPN) patient assessments as required.

2. required patient assessments conducted every shift or per facility policy.

These deficient practices pose a risk to patient health and safety if nurses are not aware of a change or do not recognize a change in their medical conditions.

Findings include:

Policy titled "Nursing Documentation" revealed: " ...Procedure: ...Daily Documentation. A. A nursing behavioral assessment must be documented at least once per shift or as needed based on the patient's condition ...3. A nursing physical/medical assessment must be documented at least once per every 24 hours or as needed based on the patient's condition ...."

Policy titled "Timeliness of Nursing Documentation" revealed: " ...Procedure: 1 ...b. Required co-signatures will be obtained no later than the end of shift with the date and time the report was signed ...2. Admission Assessment Database ...c. The Admission Assessment is the responsibility of the RN. The LPN and Nurse Aide can assist with data collection and interventions appropriate to their scope of practice ...."

Medical record review was conducted on 03/09/2022. Five (5) out of five (5) patients had at least one (1) shift with a missing or incomplete nursing behavioral assessment. Five (5) out of five (5) patients had at least one incomplete or missing daily nursing physical/medical assessment.

Further review of the medical records revealed five (5) out of five (5) patients had at least one nursing assessment that was conducted by an LPN and the assessment was not co-signed by a RN.

Employee #2 confirmed during an interview on 03/09/2022 that confirmed there should be a nursing behavioral assessment conducted on every patient every shift. Employee #2 confirmed a nursing physical/medical assessment should be conducted once every day. Employee #2 confirmed that if an LPN performs the assessment, a RN should co-sign the assessment.

Based on review of policy and procedure, medical records, and interview, it was determined that the facility failed to ensure (5) of (5) patients'' (Patients #1, 2, 3, 4, and 5) medical records were complete and accurate. Failure to document each patient encounter completely, accurately, and on time poses a patient safety risk because providers rely on documentation to communicate important patient information. Incomplete and inaccurate documentation can result in unintended and even dangerous patient outcomes.

Findings include:

The facility policy "Timeliness of Nursing Documentation" requires: " ...All medical record entries must be legible, complete, dated, timed and signed promptly, in written or electronic form, by the person (identified by name and discipline) who is responsible for the documentation ...."

Review of the "Daily Nursing Narrative" for Patients #1, 2, 3, 4, and 5 revealed multiple incomplete and illegible entries. The nurse did not document the year on multiple dated entries, and times and dates were found scribbled, scratched through, and illegible. There were multiple entries without a date entered, only the time of the entry, or only a date without time of entry.

The nursing progress notes and assessments for Patient's #1, 2, 3, 4, and 5 revealed multiple illegible signatures and omitted credentials by staff completing the record.

Employees #1 and 2 confirmed on 03/09/2022, that staff did not document in Patients #1, 2, 3, 4, and 5's medical records legibly, that staff did not include their credentials when documenting in the medical record, that staff did not document the year for dated entries, and that there were multiple entries missing dates and/or times.

Based on review of policy and procedure, medical records, and interview, it was determined that the facility failed to ensure that (5) of (5) patients' (Patients # 1, 2, 3, 4, and 5) treatment plans were complete, updated, and accurately reflected patients' progress towards treatment goals which poses a risk that patients may not receive appropriate and effective services.

Findings include:

The policy titled "Patient Treatment Plan" requires: " ...Each patient shall have a written, comprehensive, individualized treatment plan that is based on assessment of his/her medical, clinical and nursing need...Patients have the right to ongoing participation in their treatment plan ...Responsibility for ensuring that the treatment plan is accurate, up-to-date, and reviewed regularly is the responsibility of the interdisciplinary care team ...The treatment plan is reviewed regularly and revised in a manner designed to promote more effective treatment ...."

Patient #1

The patient was admitted to the facility on a Friday. The RN did not initiate a treatment plan until Sunday. The initial treatment plan was not approved by the interdisciplinary team until Thursday, six days after the patient's admission to the facility.

The weekly interdisciplinary treatment update listed problems that were either unchanged or deteriorating; however, there was no identifying patient information to indicate who was the patient referenced in the document.

The patient's medical record did not contain an updated treatment plan.

Employees #1 and 2 confirmed on 03/09/2022, that the patient's initial treatment plan was completed late and that there were no care plan updates since the initial treatment plan.

Patient #2

The patient's initial treatment plan was incompletely filled out. There was no signature, date, time, or other documentation of the nurse initiating the treatment plan.

The psychiatric provider, medical services provider, and dietary servicers personnel did not participate in the development of the interdisciplinary treatment plan.

The patient's problems list did not include any provider or nursing interventions.

The weekly interdisciplinary treatment plan update did not include any input from the interdisciplinary team.

Employees #1 and 2 confirmed on 03/09/2022, that the initial care plan was incomplete, that there were no provider or nursing interventions, and that weekly updates were not completed.

Patient #3

The patient's initial treatment plan was not dated, did not demonstrate that the patient participated in the planning, and was not signed by the medical provider, nursing services, and dietary services personnel. The initial care plan was not completed until six days after the patient's admission to the facility.

The weekly treatment plan update was incorrectly completed. The patient's "problems" were not listed, in the correct section of the document, nor were there updates for each problem.

Employees #1 and 2 confirmed on 03/09/2022, that the initial care plan was completed late and was incomplete.

Patient #4

The patient was admitted to the facility on a Friday. The RN did not initiate a treatment plan until Sunday. The initial treatment plan was not approved by the interdisciplinary team until Thursday, six days after the patient's admission to the facility.

The psychiatric provider and medical services provider did not participate in the initial treatment plan development.

Employees #1 and 2 confirmed on 03/09/2022, that the treatment plan was completed late and that the psychiatrist and medical provider did not sign as having participated in the development of the plan.

Patient #5

The initial treatment plan did not demonstrate that the patient participated in the development of the plan and was not completely filled out.

Employees #1 and 2 confirmed on 03/09/2022, that the treatment plan was not complete and did not document that the patient had participated in the development of the plan.