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Based on record review and confirmed through staff interview, nursing staff failed to assure that all needs were identified for 1 of 10 patients in the sample, by failing to conduct ongoing assessments of the patient's health condition and status. (Patient #1). Findings include:

Per record review there was no evidence that nursing conducted consistent and ongoing assessments of Patient #1's condition, during his/her hospitalization between 1/4/12 and 1/6/12. The patient presented to the ED (Emergency Department), at 7:50 AM on the morning of 1/4/12, with multiple injuries, including lacerations, abrasions and bruising and complaints of lower back pain, following a motor vehicle accident. Patient #1 underwent surgical repair of a wrist injury on the evening of 1/4/12 with the intent to discharge home following the procedure. A PACU (Post Anesthesia Care Unit) nursing assessment, at 9:48 PM, identified that both of the patient's feet were edematous (accumulation of fluid). A subsequent nurse's note, two and a half hours later, at 12:15 AM on 1/5/12, stated; "not able to bear wt on feet, c/o intense pain of top of feet." The physician was notified and an order obtained for the patient to be admitted overnight for observation. Despite the patient's inability to bear weight and complaints of pain in both feet, there was no evidence of any further assessment of the feet describing their physical condition. A nurse's note at 5:03 AM on 1/5/12 stated the physician had seen the patient and the patient had expressed no pain "except with palpation to feet by MD." A subsequent nurse's note, at 5:30 AM, indicated both feet were swollen and bruised. Although a nurse's note, at 5:45 AM that same morning, indicated the patient had been found on the floor of the room, necessitating mechanical transfer back to bed, there was no evidence of any assessment of his/her condition to identify if any injuries had been sustained in the fall. In addition, although a nurse's note at 8:30 AM stated; "went to X-ray and found potential fractures. Neurological assessment inconsistent", there was no description of the neurological assessment to indicate if the inconsistency referred to ability to feel sensation, level of consciousness; cognitive function or other. There was no further assessment of the patient's neurological status until 11:15 AM, at which time the notes indicated the patient was alert and oriented to time, place, person and purpose. The patient returned to surgery on the evening of 1/5/12 for treatment of fractures of both feet. Nurses notes following surgery indicate the patient was having difficulty following simple commands and had voiced concerns about feeling disoriented and unclear mentally. The patient's mental status and health condition continued to deteriorate and s/he was transferred to a tertiary care center for further evaluation and treatment on the evening of 1/6/12.
RN #2, who had provided care for the patient in the PACU following surgery on the evening of 1/4/12, confirmed the lack of assessment of Patient #1's feet on the morning of 1/5/12 when the patient was unable to bear weight and complained of pain. The RN stated, at the time of interview on the afternoon of 11/27/12, that the patient's feet "just did not look right."

The ED Nurse Manager confirmed, during interview at 12:44 PM on 11/28/12, the lack of full assessment and description regarding the 1/5/12, 8:30 AM documentation of a neurological assessment identified as 'inconsistent', and the lack of further neurological assessment for a period of greater than 2 hours.

The lack of assessment, following the patient's fall from bed was confirmed by both the CNO and Director of Quality during interview at 2:15 PM on 11/28/12.

Based on staff interview and record review, the CAH failed to maintain medical records with complete documentation regarding properly executed consents, pertinent medical history and evidence of assessment of the health status and patient care needs for 2 of 10 patients in the total sample. Findings include:

1. Per record review on 11/27/12 and 11/28/12, the anesthesia consent form for Patient #10, dated 5/13/12 at 10 AM, was not completely documented. The form included the signed, dated and timed signatures of the patient, the RN witness and the anesthesiologist, with the entire top section of the consent left blank. There was no description of the type of anesthesia to be used and no documentation that the risks were explained and stated to the patient prior to obtaining the patient's signature.

2. Per review of the Emergency Department Physician and Nursing Records for Patient #10, both were incompletely documented. The Physician Emergency Record for the patient failed to include the patient's history of Asthma. The Nursing Emergency Record documented only 1 set of the patient's vital signs (VS) for the greater than 3 hour stay in the Emergency Department (ED), (from 2203 hours on 5/12/12 - 0115 on 5/13/12). There was no documentation of assessment of the patient's pain levels and the effectiveness of the pain medication administered. The documentation did not meet the criteria described in the hospital's Triage Assessment Policy/Procedure. The policy stated that a patient triaged as 'Level 3' should have VS taken at least every 2 hours while in the ED. Pain assessments should be documented, including effectiveness of the medication administered.

The above findings were confirmed during interview with the CNO (Chief Nursing Officer) and the Director of Quality Assurance (QA) on 11/28/12 at 5 PM.

3. Per record review nursing staff failed to document assessments of pain for Patient #1, who presented to the ED (Emergency Department), at 7:50 AM on the morning of 1/4/12, with multiple injuries, including lacerations, abrasions and bruising and complaints of lower back pain, following a motor vehicle accident. Although the patient remained in the ED for a period of more than 9 hours and received pain medication, including; fentanyl, morphine, dilaudid or Toradol, on at least ten separate occasions, there was no assessment and/or reassessment, with the exception of 2 occasions, of the pain or effectiveness of the pain medication administered. In addition, although Patient #1 was transferred to a tertiary medial center on the evening of 1/6/12, there is no evidence of patient or patient representative signed consent for transfer and the physician signed Transfer Form lacked the date and time of transfer.

The lack of documentation of ongoing assessments and reassessments of pain during the period of time the patient was in the ED was confirmed by both the ED Nurse Manager, during interview at 1:23 PM on 11/27/12, as well as RN (Registered Nurse) #1, who had provided care to the patient in the ED, during separate interview, at 11:40 AM on 11/28/12.
The CNO confirmed, during interview at 2:15 PM on 11/28/12, the lack of date and time on the Transfer Form as well as the lack of signed consent for transfer.

Based on record review and confirmed through staff interviews the facility failed to assure that all orders of physicians or other health care professionals had signatures that were dated and/or timed with the date of entry for 2 of 10 records reviewed. Findings include:

Per record review and despite the language contained on the Physician's Orders form that stated; 'No Orders Will Be Processed Unless Dated, Timed & Signed' there was evidence that the following physician orders had been implemented after acknowledgment by nursing staff, although they each lacked the date and time the respective order entries were made:

a. Patient #1, admitted on 1/5/12, had 2 separate sets of physician orders that were each lacking both the date and time the orders were written. The orders included: "please use 4 side rails on bed to remind pt to ask for help to get out of bed" and, " MRI brain - non contrast, MRA carotid arteries".

2. Patient #2, admitted on 11/26/12, had physician orders stating; 1) Continue Niaspan 500 mg BID; atenolol 25 mg PO QD; Zetia 10 mg PO QD; 2) d/c all MVI and supplements which did not include the date and time the order was entered.

The CNO confirmed the lack of dates and times on each of the respective physician orders during interview at 2:15 PM on 11/28/12, and stated staff should have contacted the practitioner who made each of the order entries and confirmed the date and time of entry prior to implementing the orders.