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Based on medical record review and staff interview it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care related to assessments for one (#1) of ten patients sampled.

Findings include:

Patient #1 was admitted on 1/31/2015. Review of nursing documentation dated 1/31/2015 at 4:27 p.m. revealed while the patient was in the access area she stated she was "bitten by an insect". The nurse documented the patient presented with approximately a 15 mm (millimeter) hive with surrounding erythema with complaint of mild itching at the site. Review of the nursing documentation revealed no evidence where the hives were located on the patient. Review of the physician orders and medication administration record revealed orders were received and administered.

Nursing documentation on 1/31/2015 at 7:30 p.m. revealed the patient was bitten on the right wrist while in the access area, apparently by a spider. Review of the documentation revealed no evidence of a description of the right wrist appearance. Review of the record revealed no further documentation of the affected area.

Documentation by the psychiatrist on 2/2/2015 stated the patient reported hives. Benadryl was given but the patient stated it was not working. The physician did not document the location or a description of the hives. Documentation revealed the patient's medication was changed to treat the hives. There was no evidence the patient's hives were reassessed by an RN (Registered Nurse).

Interview with the ADON (Assistant Director of Nursing) on 2/26/2015 at approximately 11:00 a.m. confirmed the above findings.

Based on medical record review and staff interview it was determined the facility failed to develop a complete and keep current a nursing care plan for one (#1) of ten patients sampled.

Findings include:

Patient #1 was admitted on 1/31/2015. Review of the initial nursing assessment documentation revealed the patient reported being bit by an insect and had developed hives. Review of the physician orders and medication administration record revealed medication by mouth and topical cream was ordered and administered.

Nursing and physician documentation on 2/2/2015 revealed the medication prescribed did not help and a change in medication was ordered. Review of the patient's treatment plan revealed no evidence the patient's hives were identified on the treatment plan.

Interview with the Assistant Director of Nursing on 2/26/2015 at approximately 11:00 a.m. confirmed the findings.