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Based on document review and interview, the facility failed to ensure patient rights were adhered to related to personal belongings in three (patients 1, 2 and 8) of 10 patient's medical records (MR) reviewed .

Findings include:

1. Review of facility policy, PERSONAL BELONGINGS INVENTORY, Revised: 2/2018, Policy No.: III-B.28, indicated the following, upon admission, a staff member will inventory all patient belongings, and sign the Personal Belongings Inventory Form or document in the patient record that belongings were sent with the patient upon discharge.

2. Patient 1's medical record (MR), PATIENT BELONGING INVENTORY indicated the following, inventory upon discharge, discharge staff signed and dated (02/20/18), but did not indicate inventory upon discharge. Patient 2's medical record (MR), PATIENT BELONGING INVENTORY indicated the following, inventory upon discharge, discharge staff signed and dated (12/28/17), but did not indicate inventory upon discharge. Patient 8's MR, PATIENT BELONGING INVENTORY indicated the following, inventory upon discharge, discharge staff signed and dated (01/06/18), but did not indicate inventory upon discharge.

3.Interview on 3/29/2018, at approximately 2:10 pm, with N1 (Chief Operating Officer) the following was confirmed, patients 1, 2 and 8's medical records unable to determine inventory on discharge.

Based on document review and interview the facility failed to ensure nursing care was supervised and evaluated in two ( patient 3 and 5) of 10 patient's medical records (MR) reviewed and failed to develop policy for routine skin assessments.

Findings include:

1. Review of facility policy, SKIN/PRESSURE ULCER ASSESSMENT AND PREVENTION, Revised 10/2017, Policy No.: II-D.2, indicated the following, 2. Patients with Moderate Risk and/or a Stage I Pressure Ulcer
a. The patient will receive all interventions listed above, in addition to : i. The patient will be turned and repositioned (or cued to do so ) at a minimum of every two hours, avoiding positioning patient on affected side.

2. Review of patient 3's medical record (MR) indicated, Nursing Care Plan-Impaired Skin Integrity date 8/12/2017, indicated decreased mobility, decreased activity, remind/assist patient with turning and repositioning a minimum of every two hours. Hourly Patient Observation Monitoring/Every 15 Minute Patient Observation Monitoring Rounds lacked indication of Q2Hrs (every 2 hours) positioning from 8/11/2017 through 9/13/2017.

3. Interview on 3/27/2018, at approximately 2:00 pm, with N2 (Chief Executive Officer) confirmed the facility has no skin assessment policy related to routine skin assessments.

4. Review of patient 5's MR indicated initial assessment 02/23/2018, 18:32. MR lacked documentation of additional skin assessments to determine skin integrity. Patient admitted on 2/23/2018 and discharged on 3/9/2018.

5. Interview on 3/29/2018, at approximately 11:15 am, with N1 (Chief Operating Officer) confirmed, patient 5's MR indicated initial skin assessment only. Interview on 3/29/2018, at 12:30 pm, with N11 (Director Health Information Management) confirmed patient 5's medical record contained only initial skin assessment. Interview on 3/29/2017, at approximately 9:52 am,with N2 ( Chief Executive Officer) confirmed patient 3's MR, Hourly Patient Observation Monitoring Rounds/Every 15 Minute Patient Observation Monitoring Rounds from 8/11/2017, through 9/13/2017 lacked documentation of turning.