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Based on Policy and Procedures, medical record reviews, and staff interviews it was determined that the facility failed to ensure the involvement of the designated representative in developing and implementing the plan of care for one (#1) of five patients sampled.

Findings included:

Review of the facility policy, "Fall Prevention Plan," revealed in section (IV) Post Fall Management, (5) Notification of fall: (d) patient's emergency contact, if the patient consents to notification. If the patient is unable to consent, notifications should occur.

Review of the medical record revealed the patient was admitted on 07/25/2020. Review of the nursing assessment revealed the patient was alert and oriented to name only and unable to make informed decisions. Review of the nursing documentation, dated 08/15/2020 at 7:35 AM, revealed the patient was found on the floor. Review of the record revealed no evidence the patient's family was notified of the patient's possible unwitnessed fall, the assessment or treatment provided, or any changes to the patient's plan of care.

On 08/25/2020 at 10:14 AM a review of the medical record with the RN Sepsis Coordinator confirmed the above findings.

Based on Policy and Procedure, medical record reviews, and staff interviews. The facility failed to ensure the register nurse supervised and evaluated the nursing care for one of five patients sampled.

Findings included:

Review of the policy, "Standards of Practice", stated (D) Weights, 3) Daily - patients should be weighed at the same time each day. A patient's weight must be documented daily for any of the following situation: (g) patients receiving tube feedings.

Review of Patient #1's medical record showed on 07/25/2020 (admission) the estimated weight of 100 kg (kilograms) documented. Review of Physician orders on 08/14/2020 revealed an order to initiate tube feedings. Further review of the record on 08/24/2020, the patient's documented weight was 80.9 kg. There was no documentation on how weight was obtained. Review of the record revealed no evidence of any additional weight measurements.

On 08/25/2020 at 10:14 AM the medical record for patient #1 was reviewed with the Register Nurse Sepsis Coordinator and confirmed the above finding.

Based on review of policy and procedures, review of agency nursing personnel files, and staff interview it was determined the facility failed to ensure the director of nursing service provided for evaluation of agency nursing personnel clinical activities for two (B, C) of five personnel files reviewed.

Findings included:

Review of the facility policy, "Performance Evaluation", #HR.LD.007, stated the scope of the policy included the nursing staff obtained from the facility contracted agency. The policy stated a formal performance evaluation would be conducted, at a minimum, on an annual basis.

Review of the personnel file for RN (Registered Nurse) "B" revealed the RN was an agency nurse that had provided clinical services at the facility since August 2017. Review of the last evaluation of the clinical activities performed by RN "B" revealed the evaluation was completed on 10/7/2019 by a separately licensed facility. There was no evidence an evaluation of the nurses clinical activities was conducted by the facility employee nursing staff.

Review of the personnel file for RN (Registered Nurse) "C" revealed the RN was an agency nurse that had provided clinical services at the facility since February 2017. Review of the last evaluation of the clinical activities performed by RN "C" revealed the evaluation was partially completed on 9/10/2019 by the contracted agency. There was no evidence an evaluation of the nurses clinical activities was conducted by the facility employee nursing staff.

An interview was conducted with the facility HR (Human Resources) Business Partner and the Director of Quality on 8/25/2020 at 10:30 am at which time the above findings were confirmed.