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Based on document review and interview the facility failed to ensure protection of patient rights related to the right of family members/designee to be informed of patient changes in condition in 1 (patient 2) of 10 closed medical records (MR) reviewed:

Findings include:

1. Policy/procedure, No. I-A. 9, Patient Rights and Responsibilities, revised/reviewed 6/18 indicated: "Receive information about your health status, course of treatment, prospects for recovery and outcomes of care, including unanticipated outcomes, in terms you can understand, tailored to the patient's age and language; have your family and/or agent, when appropriate, be informed of your care, including unanticipated outcomes, in order to participate in current and future decisions affecting your care and to participate in the development and implementation of your plan of care.

2. Review of patient 2's MR lacked documentation of communication to G1 regarding the patient's change in medical condition related to diminished lung sounds and possible pneumonia.

3 On 1/28/19 at approximately 1230 hours, staff P4 (Medical Records) was interviewed and confirmed patient 2's MR lacked documentation of facility staff communication to G1 regarding the patient's change in status.

Based on document review and interview the facility failed to ensure protection of patient rights related to the right of dignity as related to the lack of documentation of the offering and/or performing of patient Activities of Daily Living (ADL's) including providng oral care and bathing in 3 (patient 2, 3, 4) of 10 closed medical records (MR) reviewed:

Findings include:

1. Policy/procedure, No. I-A.9, Patient Rights and Responsibilities, revised/reviewed 6/18 indicated: "You have the right to be made comfortable and be treated with dignity".

2. Policy/procedure, No. I-C.1, Plan for the Provision of Nursing Care, revised/reviewed 10/18 indicated: "The practice of nursing means those functions, including basic healthcare, which people cope with difficulties in daily living associated with their actual or potential health, illness and treatment thereof... Direct and indirect patient care services that ensure safety, comfort, personal hygiene, protection of patients, and the performance of disease prevention and restorative measures by providing adequate nursing staff".

3. Review of patient 2's MR: Review of ADL's as documented on the Every 15 Minute Patient Observation Monitoring Form dated 11/28/18 through 12/16/18 lacked documentation of oral care offered and/or provided on 11/28/18, 11/29/18, 11/30/18, 12/1/18, 12/3/18, 12/4/18, 12/5/18, 12/9/18, 12/11/18, 12/12,18, 12/13/18, 12/14/18, 12/15/18. Review of ADL's Offered lacked documentation of a shower and/or bed bath being offered and/or provided on 11/28/18, 11/29/18, 11/30/18, 12/1/18, 12/2/18, 12/3/18, 12/4/18, 12/5/18, 12/6/18, 12/7/18, 12/9/18, 12/11/18, 12/12,18, 12/13/18, 12/14/18, 12/15/18 and 12/16/18.

4. Review of patient 3's MR: Review of ADL's Offered lacked documentation on 11/22/18 and 11/24/18 of daily oral care offered and/or provided. Review of patient 3's ADL's Offered lacked documentation on 11/22/18, 11/23/18, 11/24/18, 11/25/18, 11/26/18, 11/27/18, 11/29/18, 12/1/18, 12/2/18, 12/3/18, 12/4/18, 12/5/18, 12/6/18 of a shower/bed bath offered and/or provided.

5. Review of patient 4's MR: Review of ADL's Offered lacked documentation on 11/21/18, 11/22/18, 11/23/18, 11/25/18, 11/26/18, 11/27/18, 11/28/18, 12/9/18, 12/12/18, 12/16/18 and 12/19/18 of daily oral care offered and/or provided. Review of patient 4's ADL's Offered lacked documentation on 11/22/18, 11/24/18, 11/25/18, 11/26/18, 11/27/18, 11/29/18, 11/30/18, 12/1/18, 12/2/18, 12/6/18, 12/7/18, 12/8/18, 12/9/18, 12/10/18, 12/11/18, 12/12/18, 12/13/18, 12/15/18, 12/16/18, 12/18/18, 12/22/18, 12/23/18, 12/25/18, 12/26/18 and 12/27/18 of a shower/bed bath offered and/or provided.

6. On 1/28/18 at approximately 1230 hours, staff P4 (Medical Records) confirmed patient 2, 3 and 4's MR lacked documentation of ADL's offered daily to the patient including oral care and bed bath/shower. Staff P4 confirmed staff should have documented ADL's that were offered and/or performed on the Every 15 Minute Patient Observation Monitoring Form.

7. On 1/28/19 at approximately 1300 hours, staff P9 (Interim Chief Executive Officer) was interviewed and confirmed staff should document ADL's that have been offered and performed on the Every 15 Minute Patient Observation Monitoring Form. Staff P9 confirmed shower logs are posted on the units that are used as a scheduling tool for staff but are not considered to be part of MR documentation.

8. On 1/28/19 at approximately 1330 hours, staff P5 (Certified Nurse Assistant [CNA]) was interviewed and confirmed patient oral care should be offered and performed daily. Staff P5 also confirmed patient showers/bathing should be offered three times weekly.

9. On 1/28/19 at approximately 1345 hours, staff P6 (CNA) was interviewed and confirmed patient oral care should be offered and performed daily. Staff P6 also confirmed patient showers/bathing should be offered three times weekly.

Based on document review and interview, the facility failed to ensure staff document communication informing a patient's responsible party of change in medical condition; failed to ensure staff document neurological assessments post patient fall; failed to ensure staff provide treatment based on physician orders; and failed to ensure staff complete accurate documentation of a patient transfer to another facility in 1 (patient 2) of 10 medical records (MR) reviewed:

Findings include:

1. Policy/procedure, No. I-A. 9, Patient Rights and Responsibilities, revised/reviewed 6/18 indicated: "Receive information about your health status, course of treatment, prospects for recovery and outcomes of care, including unanticipated outcomes, in terms you can understand, tailored to the patient's age and language; have your family and/or agent, when appropriate, be informed of your care, including unanticipated outcomes, in order to participate in current and future decisions affecting your care and to participate in the development and implementation of your plan of care.

2. Policy/procedure, No. III-A.55, Timeliness of Nursing Medical Record Completion, revised/reviewed 8/18, indicated: "All medical record entries must be legible, complete, dated, timed and signed promptly, in written or electronic form by the person (identified by name and discipline) who is responsible for the documentation".

3. Policy/procedure, No. I-C.1, Plan for the Provision of Nursing Care, revised/reviewed 10/18, indicated on page 3: "All nursing care is planned, prescribed, coordinated and monitored by licensed nurses who have demonstrated competency to do so".

4. Policy/procedure, No. I-C.73, Transfer and Transport of a Patient, revised/reviewed 11/18, indicated: "To provide hospital staff with guidelines to follow to help assure continuity of care and communication of vital information when a patient/resident needs to be transferred or transported to another facility".

5. Review of patient 2's MR lacked documentation of communication by nursing to G1 regarding change of status related to his/her lung sounds.

6. Review of Post Fall Neurological Assessment form dated 12/1/18 lacked documentation of completed neurological checks after a fall occurring on 12/1/18 at 0615 hours. Review of Post Fall Neurological Assessment form indicates patient neurological checks are to be documented after a fall every 30 minutes times 4, every hour times 4, every 4 hours times 4, every 8 hours times 4, and then every shift per daily assessment. Review of Post Fall Neurological Assessment dated 12/1/18 indicated neurological assessments were documented on 12/1/18 at 1545, 1945, 2345 hours and 12/2/18 at 0345 hours.

7. Review of patient 2's MR lacked documentation of the patient receiving physical and occupational therapy as per frequency documented on the physical and occupational therapy evaluations and lacked documentation of physician orders for physical and occupational therapy evaluations and treatment. Review of patient 2's MR indicated a physical therapy evaluation was completed on 12/5/18. Review of Physical Therapy Evaluation dated 12/5/18 indicated: "Visit Frequency: 2-3 times per week for 6-8 weeks". Review of Physical Therapy Treatment Log indicated treatment was completed on 12/5/18 and 12/6/18. Review of patient 2's MR indicated an occupational therapy evaluation was completed on 12/6/18. Review of Occupational Therapy Evaluation dated 12/6/18 indicated: "Visit frequency 1-3 times per week for 6 weeks". Review of Occupational Therapy Daily Treatment Log indicated treatment was completed on 12/6/18, 12/11/18 and 12/13/18.

8. Review of patient 2's MR lacked clarification of the patient's transfer destination Review of Continuing Care Transfer Information form dated 12/16/18 at 1900 hours contained contradicting documentation of the patient's transport destination indicating the patient was to be transported to F2, not F1 as documented in Nursing Daily Assessment dated and Discharge Summary both dated 12/16/18.

9. On 1/28/19 at approximately 1230 hours, staff P4 (Medical Records) was interviewed and confirmed patient 2's MR lacked documentation of facility staff communication to G1 regarding the patient's change in status. Staff P4 confirmed patient 2's MR lacked documentation of physician orders for physical and occupational therapy evaluations and treatments. Staff P4 confirmed the Continuing Care Transfer Information documentation contradicted nursing and physician documentation related to the transport destination. Staff P4 confirmed post fall documentation lacked neurological assessments as indicated per the Neurological Assessment form.