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Based on clinical record review, policy and procedure review, and interview, it was determined the Emergency Department nursing staff failed to accurately assess and document patient assessments on three (#1, #5 and #9) of ten (#1-#10) patients. The failed practice did not ensure the registered nurse addressed the patients' needs and/or anticipated needs in a timely manner. The failed practice had the likelihood to affect all patients seen in the Emergency Department. Findings follow:

A. Review of the policy "Assessment/Documentation Expectation - Emergency Department" revision date of 10/23/2023 showed that the assigned nurse for the patient will be responsible for the ER (Emergency Room) adult and/or pediatric assessment, within the EMR (electronic medical record).

B. The findings of A were confirmed in an interview with the Assistant Nurse Manager of the ER on 1/10/2024 at 1:55 PM.

C. Review of Patient #1's ER clinical record dated 10/13/2023 showed there was no evidence a registered nurse performed a nursing assessment while the patient was in the Emergency Room.

D. The findings of C were confirmed in an interview with the Assistant Nurse Manager of the ER on 01/10/2024 at 1:45 PM.

E. Review of Patient #5's ER clinical record dated 01/10/2024 showed there was no evidence a registered nurse performed a nursing assessment while the patient was in the Emergency Room.

F. The findings of E were confirmed in an interview with the Assistant Nurse Manager of the ER on 01/10/2024 at 1:55 PM.

G. Review of Patient #9's ER clinical record dated 01/10/2024 showed there was no evidence a registered nurse performed a nursing assessment while the patient was in the Emergency Room.

H. The findings of G were confirmed in an interview with the Assistant Nurse Manager of the ER on 01/10/2024 at 1:55 PM.