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Based on review of facility policies and procedures and interviews it was determined the facility failed to review nursing policies periodically or have policy in place for when policies should be reviewed by the director of nursing.

Findings included:

A review of facility nursing policies and procedures revealed the following policies were not reviewed periodically to ensure compliance with the standards of nursing practice and quality of care initiatives with process improvement.

Initial Nursing Assessment and Reassessment (NS1005) dated 10/21/14
Hospital Plan for Nursing Care (NS1001) dated 10/21/14
Pain Assessment and Reassessment (NS1015) dated 10/21/14

An interview on 04/22/2016 2:00 p.m. with the chief nursing officer revealed there was no policy outlining when nursing policies should be reviewed. The chief nursing officer was unable to determine if these policies were in compliance with the standards of nursing practice and quality of care initiatives with process improvement.

Based on medical record review, interviews and policy review it was determined the registered nurse failed to ensure nursing policy for assessments and reassessment was implemented for two (#1, #2) of ten records sampled.
Failed to ensure nursing policy for medication administration was implemented for one (#1) of ten records sampled. Failed to ensure nursing policy for Interdisciplinary Care Plan was implemented for two (#1, #2) of ten records sampled

Findings Included:

1. A review of Patient #1's medical record revealed the patient was admitted on 03/06/2016 and transferred to an acute care hospital on 03/09/2016 for "food lodged in their throat". The review of the patient's medical record showed no documentation of a daily nursing reassessment for 03/09/2016.

2. A review of Patient #2's medical record revealed the patient was admitted on 03/08/2016 and transferred to an acute care hospital on 03/09/2016. The review revealed no documentation of the patient safety checks to ensure patient safety.

A review of the assessment reassessment policy and interview with the chief nursing officer revealed reassessment are to be completed daily on every patient.

3. A review of Patient #1's medication administration record (MAR) revealed it was not signed by the nurse administering the medications. The MAR had two medications initialed with the time given then blacked out with a red sticker.

A review of the policy titled "Medication Management" read "all medication management documentation must be legible including staff signatures.

4. A review of Patient #1's medical record revealed the patient was admitted to the facility on 03/06/2016 and transferred to an acute care hospital on 03/09/2016 for "food lodged in their throat". The patient returned on 03/10/2016. A review of the patient's interdisciplinary care (IDC) plan did not reveal updated documentation of the patient's change in condition.

5. A review of Patient #2's medical record revealed the patient was admitted to the facility on 04/18/2016. There was no documentation of an IDC plan being initiated or completed.

An interview with the chief nursing officer on 04/22/2016 at 2:00 p.m. confirmed the above findings.