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Based on clinical record review, policy and procedure review and interview, it was determined a Registered Nurse failed to supervise the care of patients in that vital signs were not checked daily for three (#3, #4 and #9) of fifteen (#1-#15) patients and did not ensure a medication level was available for one (#4) of fifteen (#1-#15) patients. The failed practice did not allow the Medical Staff to be aware of the patient's vital signs and medication level and make adjustments to medical treatment as necessary. The failed practice affected Patients #3, #4 and #9. Findings follow:

A. Review of Patient #3's clinical record revealed an admission date of 07/25/16 and a discharge date of 07/29/16. Review of the Vital Signs Flowsheet revealed vital signs were not recorded from 07/27/16 through 07/29/16. The findings were verified by the Chief Nursing Officer (CNO) at 1509 on 11/16/16.

B. Review of Patient #4's clinical record revealed an admission date of 07/26/16 and a discharge date of 08/05/16. Review of the Vital Signs Flowsheet revealed vital signs were not recorded on 07/27/16, 07/29/16 and 08/04/16. The findings were verified by the CNO at 1530 on 11/16/16.

C. Review of Patient #9's clinical record revealed an admission date of 07/25/16 and a discharge date of 10/02/16 and a discharge date of 10/28/16. Review of the Vital Signs Flowsheet revealed vital signs were not recorded on 10/05/16, 10/06/16 and 10/25/16. The above findings were verified by the CNO at 1425 on 11/16/16.

D. Review of the policy and procedure titled "Standards for Documentation" received from the Director of Quality/Risk Management at 1440 on 11/15/16, revealed the following: "...Procedure ...#6. Vital signs should be recorded on the vital sign sheet every day (unless a patient is on frequent vital signs, which will be recorded on the Frequent Vital Signs Sheet) ...".

E. Review of Patient #4's clinical record revealed admission orders that read "Blood level of any medication requiring level". Review of the clinical record revealed lab was drawn at 0700 on 07/27/16 but no Lithium level result was among the results. During an interview with the CNO at 1515 she verified a Lithium level should have been drawn but was not.

Based on clinical record review, interview and policy and procedure review, it was determined the Facility failed to ensure nursing groups were offered to 2 (#1 and #2) of 15 (#1-15) patients. Failure to offer nursing groups did not allow for the establishment of daily, therapeutic interactions between the staff and patient to facilitate ongoing patient assessment, observation and teaching to plan for and implement patient care. The failed practice affected Patients #1 and #2. Findings follow:
A. Review of Patient #1's multidisciplinary care plan revealed nursing groups were to be offered daily and as needed. Review of the nursing group notes revealed no nursing group offered on 07/22/16 and 07/25/16. The above findings were verified by the Unit 5 Charge Nurse at 1502 on 11/16/16.
B. Review of Patient #2's multidisciplinary care plan revealed nursing groups were to be offered 5-7 times per week. Review of the nursing group notes revealed no nursing group offered from 07/25/16 through 07/30/16. The above findings were verified by the Chief Nursing Officer at 1459 on 11/16/16.