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Based on review of policies and procedures and medical records and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) assessed, planned, supervised and reassessed/evaluated the nursing needs and care for each patient. Care/needs cannot be identified without complete baseline and ongoing assessments and evaluations that include not only psychological needs but also physiological needs. In two of two (A,B) patient records reviewed, the nurse did not perform complete nursing assessments daily so that care needs could be identified and changes in the patient's physical condition could be reported and appropriate nursing interventions could be delivered.

Findings:

1. On 09/21/2011, the surveyors requested "patient assessment and reassessment" policy. The policy states " Assessment and reassessment are ongoing integral parts of the nursing process. A continuous evaluation of patient needs and nursing interventions to meet those needs with appropriate documentation in the Nurse's notes is the expectation for all nursing staff." It is also stated that the purpose of this policy is to provide "consistent and complete patient assessments to form the basis of quality nursing care. The policy also stipulates that "nursing is a process of assessment and reassessment on an ongoing basis. RN's will document assessments each shift." Further in the policy, it stipulates. physical limitations/restrictions will be identified by patient and/or nurse and reported to the attending physician for patient specific orders. The policy also stipulates all staff members are expected to report and document any signs of change in the patient's condition to the RN: changes in vital signs, changes in level of consciousness, changes in behavior, changes in physical abilities, suspected side effects of medications. The RN is responsible to document and report the observed changes to the attending physician or physician on-call.





2. Patient #1 was a 65 Female admitted to the facility on 5/5/2011. An admissions assessment was performed on 5/5/2011 where an initial physiological and psychological assessment was performed. Patient was admitted due to significant behavioral changes, alzheimer dementia, multi-infarct with delusions, and depressive disorder non-origin specific. Patient #1 also had physiological diagnoses such chronic kidney disease, cerebral atherosclerosis, Esophageal reflux, pure hypercholesterolemia, chronic renal failure, hyperpotassemia, lumbosacral spondylosis, CVA, TIA, and dietary surveillance. On the H&P on 5/6/2011 it was stated that patient #1 had increased agitation, was throwing juice and food on the floor and then rolling around in it. Patient #1 was also observed climbing into her roommate's bed and grabbing her roommate's crotch. Patient #1 was also observed by the nurse technician performing mouth care on her that she had feces around her mouth. Patient's goal for treatment include medication adjustment and therapy to diminish sexually acting out behaviors that have potential harm to themselves or others.



3. Patient #1's initial physical assessment contained no notation or documentation about a bruise located on the patient's back. On the following days; 5/6/2011, 5/7/2011, 5/8/2011, 5/9/2011, 5/10/2011, 5/11/2011, 5/12/2011, 5/13/2011, 5/14/2011, 5/15,2011, 5/16/2011, 5/17/2011, and 5/18/2011 the facility's licensed staff failed to perform a daily assessment on the patient's full body sytem's. On the days listed above, the patient did not have a complete full body assessment performed by a registered nurse.