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Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by the registered nurse failing to perform a complete initial nursing assessment upon admit for 1 (#1) of 5 (#2, #3, #4, #5) patient medical records reviewed.

Findings:

Review of the hospital's policy titled Initial Nursing Assessment, Document Number PC-402, revised September 2019 revealed in part: It shall be the responsibility of a registered nurse to perform an initial assessment within eight hours of admission.

Review of the medical record for patient #1 revealed a 79 year old female admitted to the hospital on 03/03/2022 for Visual and Auditory Hallucinations. The patient had a history of COPD, HTN, GERD, Acute Respiratory Failure, MI, and Oxygen Dependent. She required a wheelchair for extended mobility. There was no documentation of an Initial Nursing Assessment.

In an interview on 03/31/2022 at 8:30 a.m. with S1NM confirmed there was no documented Initial Nursing Assessment for patient #1.

Based on record review and interview, the Director of Nursing failed to ensure the nurses adhered to the policies and procedures of the hospital. This deficiency is evidenced by missing Nursing Shift Assessments for 4 (#1, #2, #3, #4) of 5 (#1, #2, #3, #4, #5) medical records reviewed for missing nursing shift assessments.

Findings:

Review of the hospital's policy titled Nursing, Document Number PC- 602, revised September 2019 revealed in part: 1) The Nurse's documentation should include the following: a) A chart entry shall be made every shift on every patient. c) Precautions. d) Observations of the patient's behavior and physical condition. e) Description of the degree a patient participates in unit activities. f) Group interventions and the patient's responses ...

Patient #1
Review of the medical record for patient #1 revealed missing Nursing Shift Assessments on 03/04/2022 for the 6:00 a.m. shift, 03/06/2022 for the 6:00 a.m., and the 6:00 p.m. shift, 03/07/2022 for the 6:00 a.m. shift, 03/08/2022 for the 6:00 a.m. shift, 03/09/2022 for the 6:00 p.m. shift, 03/10/2022 for the 6:00 a.m., and 6:00 p.m. shift, 03/11/2022 for the 6:00 a.m. shift, 03/14/2022 for the 6:00 a.m. shift, 03/15/2022 for the 6:00 a.m., and 6:00 p.m. shift, 03/17/2022 for the 6:00 p.m. shift, and 03/18/2022 for the 6:00 a.m., and 6:00 p.m. shift.

Patient #2
Review of the medical record for patient #2 revealed missing Nursing Shift Assessments on 03/14/2022 for the 6:00 a.m. shift, 03/15/2022 for the 6:00 a.m. and 6:00 p.m. shift, 03/17/2022 for the 6:00 a.m. shift, and 03/18/2022 for the 6:00 a.m. shift.

Patient #3
Review of the medical record for patient #3 revealed missing Nursing Shift Assessments on 02/10/2022 for the 6:00 p.m. shift, 02/13/2022 for the 6:00 a.m. shift, 02/14/2022 for the 6:00 p.m. shift, 02/15/2022 for the 6:00 p.m. shift, 02/18/2022 for the 6:00 p.m. shift, 02/19/2022 for the 6:00 p.m. shift, 02/20/2022 for the 6:00 p.m. shift, 02/23/2022 for the 6:00 p.m. shift, 02/24/2022 for the 6:00 p.m. shift, 02/28/2022 for the 6:00 p.m. shift, 03/01/2022 for the 6:00 a.m., and 6:00 p.m. shift, and 03/02/2022 for the 6:00 a.m. shift.

Patient #4
Review of the medical record for patient #4 revealed missing Nursing Shift Assessments on 02/17/2022 for the 6:00 p.m. shift, 02/18/2022 for the 6:00 p.m. shift, 02/19/2022 for the 6:00 p.m. shift, 02/20/2022 for the 6:00 p.m. shift, 02/23/2022 for the 6:00 p.m. shift, 02/24/2022 for the 6:00 p.m. shift, 02/27/2022 for the 6:00 p.m. shift, 02/28/2022 for the 6:00 p.m. shift, 03/01/2022 for the 6:00 a.m., and 6:00 p.m. shift, 03/03/2022 for the 6:00 a.m. shift, and 03/04/2022 6:00 a.m. shift

In an interview on 03/31/2022 at 10:00 a.m. with S1NM verified the missing records.