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Based on medical record review and policy review, the nursing staff did not document an assessment of Patient #1's condition in a timely manner. This has the potential to adversely effect the continuity of patient care.

Findings include:

Review on 03/24/16 of policy " Documentation Requirements in the Medical Record: MR.16 " last facility revision 02/2016 revealed patient record entries should be documented at the time the treatment is rendered. Late entry documentation in the patient record should occur at or near the time of the event being recorded. Modification to medical record documentation is discouraged.

Review on 03/24/16 of policy " Documentation of Adult/Pediatric Patient care: PE.2 " last revision 03/2010 revealed the registered nurse (RN) is accountable for documentation from admission through discharge. Progress notes are written by the RN for changes in patient condition and patient ' s response to interventions.

Medical record review on 03/23/16 revealed a nursing progress note was entered on 02/03/16 documenting the patient's condition on 01/24/16 between the hours of 7:00am and 7:00pm. Patient #1 was discharged on 02/01/16.