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Based on record reviews and interviews, the facility failed to ensure that nursing staff documented accurate assessments and events that occurred for 1 of 8 patients (Patient #1) reviewed. This deficient practice placed all patients in the facility at high risk for undetected, untreated serious illness and/or injury.

Findings included:

Patient#1:

Record review of the facility in-patient hospital records revealed the following information:
- Patient #1 was a 67-year-old female who was admitted on 07/02/2021 for an elective knee replacement.

- Record review of the Physician's History and Physical, dated 08/16/2021 revealed the following:
-Patient is a 67-year-old-female, history of depression and dementia who was brought to the hospital on 07/02/2021 for an elective knee replacement. She was driving and independant at home.

- Further review of the facility medical record revealed that nursing staff failed to document nursing checks for patient #1, who was less than 24 hours postoperative. In addition, nursing staff failed to document the events that occured when Patient #1 was found unresponsive in her room. Nursing staffs also failed to document/ give report to the nursing staff who accepted the patient on the Intensive Care Unit after cardiac arrest.

-Record review of the facility policy entitled: "Assessment/ Re-Assessment", reviesed on 3/2020, revealed the following:

1.) All patients at this Facility receiving inpatient, outpatient or emergency services will have an initial assessment and appropriate follow-up assessments based upon their individual physical, psychological, social and cultural needs.
2.) This assessment process will determine the need for care and/or treatment, the type of care to be provided and the patient's needs through the continuum of care.
3.) The goal of the assessment/reassessment process is to provide the patient with the appropriate care to meet individual and potentially changing needs.

6.) Assessments provided by health-care professionals will be based upon and include:
a.) Data collected to assess the needs of the patient.
b.) Analysis of data to develop a plan to meet the patient's care or treatment needs.
c.) Prioritization of decisions based upon analysis of data regarding patient care needs. Decisions made regarding patient care or treatments are prioritized based on analysis of the information collected.

I.) Assessment Framework

The assessment framework to identify patient needs will be structured around two components. Initial screening and assessment/reassessment of all patients as appropriate to the clinical discipline and as individual patient condition changes
regarding patient care or treatments are prioritized based on analysis of the information collected.

PROCEDURE:

The assessment framework to identify patient needs will be structured around two components. Initial screening and assessment/reassessment of all patients as appropriate to the clinical discipline and as individual patient condition changes.

Department specialty specific patient assessments will be guided by the data to be collected, the scope of the assessment necessary, mechanisms designed to analyze the data collected, and the framework for decision making based upon the analysis of data.

All departments have responsibility for review of the portion of the patient's medical record that directly relates to each department's scope of care and clinical involvement with the patient. Assessment information will be evaluated by various clinical disciplines to identify and prioritize the patient's needs, treatment and discharge planning.

A.) Information generated via a patient's assessment by various clinical disciplines will be integrated to identify and prioritize the patient's needs for care and treatment.
1.)The various disciplines will provide information concerning patient assessment relevant to their scope of care.
2.)Areas of concern or patient's special needs may be identified by specific clinical disciplines. All departments, patients and family members may request further evaluation for specific needs.
3.)The patient assessment will be age specific (neonatal, pediatric, adolescent, adult or geriatric) and includes physical, psychological, social, cultural, educational, nutritional, spiritual preferences and daily activities of the patient.
4.)The expectations of the family and/or guardian are taken into account for their involvement in the assessment process, treatment and/or continuous care of the patient.
5.)Initial assessment of the patient needing nursing care (in all settings [departments] where nursing care is provided) is performed by a RN to identify and prioritize nursing care needs. Further assessment and reassessment will be based on a collaborative effort among all health care providers.
6.)Employees of all departments throughout the hospital that interact with patients share responsibility in identifying possible victims of alleged or suspected abuse or neglect.


In an interview conducted on 11/08/2022 at 1:00 PM, facility Nursing administrative staff confirmed the inconsistencies in nursing documentation for patient #1, and the lack of documentation regarding nursing follow-up and care interventions/ care planning.