HospitalInspections.org

Based on medical record review, policy and procedure review and staff interview, the hospital failed to ensure a Registered Nurse (RN) evaluated the care for all patients.
This occurred in 13 open and closed medical records reviewed.

Findings:

1. On the morning of March 17, 2016, the surveyor reviewed 13 open and closed patient medical records.

2. Multiple patient medical records reviewed contained shift assessments done by Licensed Practical Nurses (LPNs). The assessments done by LPNs were not co-signed by an RN. There was no evidence an RN was involved in the patient care when an LPN had done the assessment and was assigned the patient.

3. On the morning of March 17, 2016, Staff C told surveyors RNs did not co-sign an LPN assessment. Staff C told surveyors an RN did the initial assessment but did not have to be the nurse that did shift assessments.

4. On the morning of March 17, 2016, the surveyor reviewed a policy and procedure titled, "Scope of Assessment/Reassessment." The policy documented, "...An RN completes the remainder of the nursing assessment and verifying information obtained by th LPN..." The policy further documented, "...An RN assesses the patient's needs for nursing care in all settings..."