Bringing transparency to federal inspections
Tag No.: A0392
Based on review of medical records and staff interviews it was revealed the facility failed to ensure the nursing staff completed a nursing assessment prior to a patient's discharge. This deficiency was identified in ten (10) of ten (10) medical records reviewed ( patient #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). This deficiency has the potential to adversely affect all patients.
Findings include:
1. A review of the medical record for patient #1 was conducted on 3/11/19 and it revealed no nursing assessment was completed prior to discharge.
2. A review of the medical record for patient #2 was conducted on 3/12/19 and it revealed no nursing assessment was completed prior to discharge.
3. A review of the medical record for patient #3 was conducted on 3/12/19 and it revealed no nursing assessment was completed prior to discharge.
4. A review of the medical record for patient #4 was conducted on 3/12/19 and it revealed no nursing assessment was completed prior to discharge.
5. A review of the medical record for patient #5 was conducted on 3/12/19 and it revealed no nursing assessment was completed prior to discharge.
6. A review of the medical record for patient #6 was conducted on 3/12/19 and it revealed no nursing assessment was completed prior to discharge.
7. A review of the medical record for patient #7 was conducted on 3/12/19 and it revealed no nursing assessment was completed prior to discharge.
8. A review of the medical record for patient #8 was conducted on 3/12/19 and it revealed no nursing assessment was completed prior to discharge.
9. A review of the medical record for patient #9 was conducted on 3/12/19 and it revealed no nursing assessment was completed prior to discharge.
10. A review of the medical record for patient #10 was conducted on 3/12/19 and it revealed no nursing assessment was completed prior to discharge.
11. An interview was conducted with the Nurse Manager on 2/12/19 at 9:50 a.m. When asked about a nursing assessment prior to discharge she stated, "It is not a policy for nursing to do a nursing assessment prior to discharge but it is an expectation of the facility that a nursing assessment will be completed."
12. An interview was conducted with the Nurse Manager on 2/12/19 at approximately 2:40 p.m. She concurred nursing assessments are not completed before a patient is discharged.