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Based on observation, interview, record, and document review, the hospital failed to ensure that a Registered Nurse (RN) 16 who completed the hospital's preceptorship (department specific new employee orientation), was competent to perform all nursing tasks independently. RN 16 did not accurately complete an admission nursing nutritional assessment, for 1 of 31 sampled patients (7). The lack of assessment accuracy did not ensure that nursing communicated all aspects of the assessment to the interdisciplinary staff in an effort to sustain continuity of care.

Findings:

On 3/29/16 at 4:30 P.M., a tour of the Rehabilitation unit (patient care unit where physical, occupational and speech therapies are conducted) with the Director of Telemetry (DOT), Director of Surgery (DOS), Rehabilitation Manager (RM) and Registered Nurse (RN) 16.

On 3/29/15 at 4:50 P.M., an interview and review of Patient 7's medical record was conducted with the RM and RN 16.

Patient 7 was admitted to Hospital A on 3/17/16 with diagnosis which included severe protein-calorie malnutrition per the History and Physical, dated 3/18/16.

Patient 7's nursing nutritional assessment indicated "...yes to any of the questions above, click yes to the next question to order a nutritional consult." Patient 7's assessment indicated yes to three of the questions; however, the section to order a nutritional consult was marked "no".

During the interview, RN 16 stated the purpose of the nursing nutritional assessment was to assist staff with determining the appropriate nutritional needs for the patient. RN 16 acknowledged that the assessment criteria triggered a dietary consult. RN 16 acknowledged that he should have clicked yes to the next question which would have led to a nutritional consult order. In addition, RN 16 stated that he was a new employee who recently completed the hospital's preceptorship.

On 3/30/16 at 10:40 A.M., RN 16's employee file was reviewed with a Human Resources staff (HR) 1 and the RM. RN 16's "RN/LVN (Licensed Vocational Nurse) General Orientation Skills Summary"(Competency), dated 3/8/16- 3/26/16, was reviewed. The assessment legend indicated the following scores: 1: Minimal experience-need additional teaching/practice, 2: Moderate experience-can perform without supervision, 3: Experienced-Thorough knowledge, no supervision required. RN 16's competency related to admission assessment/documentation, indicated a score of 1 which was the employee's self assessment.

On 3/30/16 at 11:45 A.M., an interview was conducted with the RM. The RM acknowledged that RN 16's competency showed that RN 16's self assessment was scored as a 1 (minimal experience-need additional teaching/practice) for admission assessment documentation. He agreed that if RN 16 felt that he needed additional teaching/practice, RN 16 should not have been independently performing and documenting assessments. In addition, the RM acknowledged that Patient 7's assessment indicated yes to three of the questions which would have resulted in a nutritional consult order. The RM acknowledged that an accurately documented assessment was an essential part of nursing communication amongst the interdisciplinary staff involved in the patient's care.