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Based on clinical record reviews, document reviews and interviews it was revealed the facility failed to ensure a Registered Nurse (RN) conducted an initial physical assessment for patients #1, 7 and 8. This failure was identified in three (3) out of twenty (20) clinical records. This failure has the potential to place all patients at risk for an adverse event.

Findings include:

1. A review of the clinical record for patient #1 revealed the patient was admitted to the Swing Bed Unit on 07/06/20 at 2:45 p.m. and an initial physical assessment was conducted at 4:04 p.m. by Licensed Practical Nurse (LPN) #2.

2. A review of the clinical record for patient #7 revealed the patient arrived on the Inpatient Unit on 07/17/20 at 9:46 a.m. and an initial physical assessment was conducted at 10:32 a.m. by LPN #2.

3. A review of the clinical record for patient #8 revealed the patient arrived on the Inpatient Unit on 07/16/20 at 11:44 a.m. and an initial physical assessment was conducted at 12:00 p.m. by LPN #3.

4. A review of policy "Standards For Nursing Practice and Care," approved 07/2019, states in part: "The Registered Professional Nurse shall conduct and document nursing assessments of the health status of individuals ... The Registered Professional Nurse shall supervise others to whom nursing interventions are delegated. ... The Licensed Practical Nurse practicing under the direction of a Registered Professional Nurse, ... shall: Contribute to the nursing assessment by: Collecting, reporting and recording objective and subjective data in an accurate and timely manner. Data collection includes but is not limited to observation of: The condition or change in condition of a client, and signs and symptoms of deviation from normal health status."

5. A review of the "Position Description of the Registered Nurse," not dated, states in part: "The following are the general expected duties of this position ... Provides initial and ongoing assessment and interpretation of patients and caregivers within the framework of holistic professional nursing practice ...."

6. A review of the "Position Description of the Licensed Practical Nurse," not dated, states in part: "Collects and records patient history ... Accepts direction and instruction from the providers and Registered Nurse on staff ...."

7. An interview was conducted on 09/30/20 at approximately 8:32 a.m. with the Director of Case Management. When asked if the RN should conduct the initial physical assessment she stated in part: "The RN should conduct the first physical assessment or signed off on the LPN's physical assessment and a note should have been written."

8. An interview was conducted on 09/30/20 at approximately 12:00 p.m. with Nurse Manager #1. When asked if the RN should conduct the initial physical assessment he stated in part: "My expectation is the RN will be there with the LPN and sign off on the initial assessment. ... The RN oversees LPN's patients. I do expect the RN to do the initial assessments. ... If it's not documented, then it's not done."

9. An interview was conducted on 09/30/20 at approximately 1:20 p.m. with RN #3. When asked if she supervised the LPN and oversees care provided to their patients she stated in part: "What are you supervising? If I have my own assignment, I don't ever oversee their patients. I've never been assigned to oversee their patients."

Based on clinical record reviews, document reviews and interviews it was revealed the facility failed to ensure a Registered Nurse (RN) supervises and evaluates the nursing care provided by a Licensed Practical Nurse (LPN) for patients #1, 7 and 8. This failure was identified in three (3) out of twenty (20) clinical records. This failure has the potential to place all patients at risk for an adverse event.

Findings include:

1. A review of the clinical record for patient #1 revealed the patient was admitted to the Swing Bed Unit on 07/06/20 at 2:45 p.m. and an initial physical assessment was conducted at 4:04 p.m. by Licensed Practical Nurse (LPN) #2.

2. A review of the clinical record for patient #7 revealed the patient arrived on the Inpatient Unit on 07/17/20 at 9:46 a.m. and an initial physical assessment was conducted at 10:32 a.m. by LPN #2.

3. A review of the clinical record for patient #8 revealed the patient arrived on the Inpatient Unit on 07/16/20 at 11:44 a.m. and an initial physical assessment was conducted at 12:00 p.m. by LPN #3.

4. A review of policy "Standards For Nursing Practice and Care," approved 07/2019, states in part: "The Registered Professional Nurse shall conduct and document nursing assessments of the health status of individuals ... The Registered Professional Nurse shall supervise others to whom nursing interventions are delegated. ... The Licensed Practical Nurse practicing under the direction of a Registered Professional Nurse, ... shall: Contribute to the nursing assessment by: Collecting, reporting and recording objective and subjective data in an accurate and timely manner. Data collection includes but is not limited to observation of: The condition or change in condition of a client, and signs and symptoms of deviation from normal health status."

5. A review of the "Position Description of the Registered Nurse," not dated, states in part: "The following are the general expected duties of this position ... Provides initial and ongoing assessment and interpretation of patients and caregivers within the framework of holistic professional nursing practice ...."

6. A review of the "Position Description of the Licensed Practical Nurse," not dated, states in part: "Collects and records patient history ... Accepts direction and instruction from the providers and Registered Nurse on staff ...."

7. An interview was conducted on 09/30/20 at approximately 8:32 a.m. with the Director of Case Management. When asked if the RN should conduct the initial physical assessment she stated in part: "The RN should conduct the first physical assessment or signed off on the LPN's physical assessment and a note should have been written."

8. An interview was conducted on 09/30/20 at approximately 12:00 p.m. with Nurse Manager #1. When asked if the RN should conduct the initial physical assessment he stated in part: "My expectation is the RN will be there with the LPN and sign off on the initial assessment. ... The RN oversees LPN's patients. I do expect the RN to do the initial assessments. ... If it's not documented, then it's not done."

9. An interview was conducted on 09/30/20 at approximately 1:20 p.m. with RN #3. When asked if she supervised the LPN and oversees care provided to their patients she stated in part: "What are you supervising? If I have my own assignment, I don't ever oversee their patients. I've never been assigned to oversee their patients."

Based on clinical record reviews, document reviews and interviews it was revealed the facility failed to maintain a clinical records system following policy and procedures which requires staff signatures to include their professional credentials. This failure was identified in twenty (20) out of twenty (20) clinical records. This failure has the potential to place all patients at risk for quality of patient care provided by unidentified, credentialed healthcare professionals.

Findings include:

1. A review of the clinical records for patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20 revealed clinical staff's documentation failed to include their professional credentials with their electronic signatures.

2. A review of policy "Medicare Signature Requirements," approved 03/2019, states in part: "The signature for each entry must be legible and should include the practitioner's first and last name, and applicable credentials."

3. An interview was conducted on 09/30/20 at approximately 1:58 p.m. with the Chief Nursing Officer. When asked if nursing staff's electronic signatures should include credentials, she concurred.