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Based on clinical record review and interview, it was determined the facility failed to ensure a Registered Nurse evaluated the nursing care each 12-hour shift for 7 (#3-#9) of 10 (#1-#10) patients reviewed based on lack of documentation in the clinical record. The failed practice had the potential to affect all patients admitted to the facility. Evidence follows:

A. Review of the clinical record for Patient #3 revealed lack of documentation of RN observation or evaluation of the patient during the AM shift on 09/29/10. The lack of documentation of RN observation or evaluation of the patient was confirmed during interview at 0940 on 10/04/10 by the Clinical Care Director of Compass.

B. Review of the clinical record for Patient #4 revealed lack of documentation of RN observation or evaluation of the patient during the AM shift on 09/29/10 and the PM shifts on 09/16, 09/17, 09/18, 09/22 and 09/28/10. The lack of documentation of RN observation or evaluation of the patient was confirmed during interview at 1000 on 10/04/10 by the Program Director of Compass.

C. Review of the clinical record for Patient #5 revealed lack of documentation of RN observation or evaluation of the patient during the PM shifts on 09/30 and 10/01/10. The lack of documentation of RN observation or evaluation of the patient was confirmed during interview at 1015 on 10/04/10 by RN #1.

D. Review of the clinical record for Patient #6 revealed lack of documentation of RN observation or evaluation of the patient during the PM shifts on 10/01and 10/02/10. The lack of documentation of RN observation or evaluation of the patient was confirmed during interview at 1020 on 10/04/10 by the Clinical Care Director of Compass.

E. Review of the clinical record for Patient #7 revealed lack of documentation of RN observation or evaluation of the patient during the AM shift on 10/01/10 and the PM shift on 10/01/10. The lack of documentation of RN observation or evaluation of the patient was confirmed during interview at 1000 on 10/04/10 by the Program Director of Compass.

F. Review of the clinical record for Patient #8 revealed lack of documentation of RN observation or evaluation of the patient during the AM shift on 10/03/10 and the PM shifts on 10/01 and 10/03/10/10. The lack of documentation of RN observation or evaluation of the patient was confirmed during interview at 1045 on 10/04/10 by the Program Director of Compass.

G. Review of the clinical record for Patient #9 revealed lack of documentation of RN observation or evaluation of the patient during the AM shift on 10/03/10 and the PM shift on 10/01/10. The lack of documentation of RN observation or evaluation of the patient was confirmed during interview at 1100 on 10/04/10 by the Program Director of Compass.