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Based on review of facility policies/procedures, the medical record, documents, and staff interviews, it was determined the facility failed to ensure a policy/procedure for nursing standard of care was established and implemented to identify facility requirements for how frequently vital signs were to be taken on patients, which poses the potential risk for patient harm when nursing personnel does not have guidelines to follow to properly care for patients.

Findings include:

Surveyor requested the facility policy on Nursing Standard of Care that addressed how frequently vital signs were taken on patients on the different units. ,

No policy/procedure regarding Nursing Standard of Care for taking vital signs on patients was provided.

There is a policy that addressed the frequency of measuring intake and output.

There is no policy to clarify frequency of vital signs.

Review of Patient #1's admission orders revealed that vital signs and intake/output were ordered "per protocol."

Employee #1 confirmed during an interview conducted on 03/06/19, that there is not a policy that addresses how often vital signs are taken on patients. When asked how a registry nurse would know how often to take vitals on a patient, Employee #1 stated that they are done "per protocol", however, Employee # 1 was unable to provide any documentation supporting protocol for taking of vital signs.













There is not a policy/procedure regarding Nursing Standards of Care. Missing information includes: frequency of patient rounds by nursing staff, frequency of vital signs for the different units, activities of daily living, frequency of hygiene (ex. linen/gown change, peri care, oral care, toileting), and regarding the prevention of skin breakdown, what patients should be repositioned and how frequently.

Review of Patient #1's admission orders revealed that vital signs and intake/output were ordered "per protocol." There is a policy that addresses the frequency of measuring intake and output. There is not one for frequency of vital signs.

During an interview conducted on 03/06/19, Employee #1 confirmed that there is not a policy that addresses the above items. When asked how a registry nurse would know how often to take vitals on a patient, Employee #1 stated that they are done "per protocol", but was unable to produce any documentation supporting this.

Based on review of facility policies/procedures, the medical record, documents, and staff interviews, it was determined the facility failed to ensure that nursing personnel documented activities of daily living in the patient's medical record. This deficient practice poses a potential risk to the health and safety of patients, when patient activities are not monitored.

Findings include:

Surveyor requested the facility policy identifying how often staff were required to document activities of daily living, IE: how often patient rounds were conducted by nursing staff, frequency of hygiene care (ex. linen/gown change, peri care, oral care), the prevention of skin breakdown, and what patients should be repositioned and how frequently.

The policy titled "Fall Prevention Program" requires staff to: "...encourage and assist patient with toileting every two hours ...encourage use of the call light, position the call light within reach and answer immediately...provide assistance with transfers, always using a gait belt...educate patient not to attempt transferring out of bed without help ...."

Review of the medical record revealed that Patient #1 was on fall precautions for the duration of the hospitalization.

Review of the "System Observation Data Collection" forms for Patient #1 revealed that there was no documentation on Patient #1's use of the restroom or bedside commode on 18 of 27 days.

Review of the "System Observation Data Collection" forms for Patient #1 revealed a Safety Assessment, which includes interventions such as call light in reach, bed low position, side rails up, and patient observation. On day shift (7a-7p), there was one day with no documentation. Safety Assessment documentation was recorded every two hours on 16 of 26 days. Safety Assessment documentation was recorded hourly on eight of 26 days.
On night shift (7p-7a), Safety Assessment documentation was recorded every two hours on ten of 25 nights. Safety Assessment documentation was recorded hourly on 14 of 25 nights. Staff failed to document their Safety Assessments (risk for falls) consistently within the same timeframe, hourly or every two hours.

Employee #1 confirmed on 03/06/19, that there is not a policy that specifically addresses the required frequency of documentation or observation for a patient at risk for falls.

There is no documentation of any hygiene activities (i.e. bath/shower, oral care, peri care, linen change) for five of 27 days. No bath/shower was documented on 20 of 27 days. No oral care was documented on 8 of 27 days. No peri care was documented on 11 of 27 days. No linen change was documented on 12 of 27 days.

Employee #1 confirmed during an interview conducted on 03/06/19, the above documentation was not present in the medical record.