HospitalInspections.org

Based on record review, document review and interviews it was revealed the facility failed to ensure that applicable Federal, State and local law requirements are met in (1) out of thirty (30) patients. This failure has the potential to cause great harm to all patients receiving care at the facility.

Findings include:

1. A review of patient #1's medical record revealed an admission assessment was documented by a Registered Nurse (RN#1) on 07/01/20 at 8:34 p.m. A nursing care plan was initiated by RN #1 on 07/01/20 at 8:40 p.m. A limited assessment was conducted by a different RN on 07/02/20 at 4:13 a.m. No further nursing documentation by a RN was noted. The patient was discharged on 07/04/20.

2. A review of "Title 10 Legislative Rule State Board of Examiners for Licensed Practical Nurses Series 3 Legal Standards of Nursing Practice" revealed it states in part: "10-3-4. Standards Relating to the Licensed Practical Nurse's Responsibilities as a Member of the Health Care Team. The Licensed Practical Nurse (LPN) shall: 4.5. function under the direction of a registered professional nurse, licensed physician, or licensed dentist; 4.6. consult with the registered professional nurse to seek guidance in delivery of nursing care as necessary; 4.7. obtain instruction and supervision as necessary from the registered professional nurse when implementing nursing techniques or practices."

3. The hand-written staffing assignments were reviewed for Unit Two (2) North from 07/01/20 through 07/04/20, both day shift and night shift. Patient #1 was assigned to staff listed as LPNs each shift until he was discharged.

4. A telephone interview was conducted with the Director of Two (2) North on 08/25/20 at 8:57 a.m. When asked about patient assignments on his unit he stated, "The RN is responsible for all care on their end of the hallway. Typically if an LPN is assigned a set of patients on one shift, the next shift an RN would be assigned. It rotates back and forth so an RN is caring for the patient sometime within twenty-four (24) hours. I'm not sure what had happened with patient #1 being assigned an LPN each shift on each day he was here."

5. A telephone interview was conducted with RN #2 on 08/25/20 at 9:46 a.m. She discussed that sometimes she was relief Charge Nurse and makes nursing assignments for night shift. She stated, "I try to alternate LPN and RN so there is a RN next to each LPN. We call them RN buddies. The RNs do not review the LPN documentation or get report on the LPN's patients. The LPNs take care of their own patients."

6. A telephone interview was conducted with the Charge Nurse of Two (2) North on 08/25/20 at 11:49 a.m. Regarding assignments on her unit she stated, "Each LPN has a RN buddy who can help them with their patients if they need something. The RN does not receive report on the LPN's patients and only would see them if the LPN asked. The RN does not review the LPN's charting to see if everything is done. The RN does not verify if the LPN is following the plan of care. I was never told we were responsible for any LPN's patients. The LPNs are in charge of their own patients."

7. A telephone interview was conducted with RN #3 on 08/25/20 at 12:14 p.m. Regarding assignments on her unit she stated, "I was never told I was responsible for the LPN's patients. If the LPN has a problem with their patient they come to us or the Charge Nurse and we would help. We do not take over care of their patient if there is a problem. We do not review their documentation to ensure care was completed. We don't receive report on their patients."

8. A telephone interview was conducted with the Director of Two (2) North on 08/25/20 at 12:33 p.m. He stated, "The RN is supposed to sign off on all LPN assessments each shift. I'm not sure why or when this has stopped."

9. A telephone interview was conducted with the Director of Nursing on 08/25/20 at 1:23 p.m. She stated, "My expectation is that the RN would review the LPN's documentation at least once in a twenty-four (24) hour period. I do not know what happened on that unit (Two (2) North). It will be fixed and fixed today."

Based on document review and interviews it was revealed the governing body did not appoint the Chief Executive Officer (CEO). This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

1. A review of the governing body meeting minutes from October 2016 announced the new CEO to the governing body.

2. An email received from the Director of Risk and Patient Safety on 08/25/20 at 3:49 p.m. stated, "This is what we have from the BOT (Board of Trustees) regarding the CEO."

Based on record review, document review and interviews it was revealed care was not provided in a safe setting for one (1) out of thirty (30) patients (patient #1) in relation to care being supervised by a Registered Nurse (RN). This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

1. A review of patient #1 medical record revealed an admission assessment was documented by a Registered Nurse (RN#1) on 07/01/20 at 8:34 p.m. A Nursing Care plan was initiated by RN #1 on 07/01/20 at 8:40 p.m. A limited assessment was conducted by a different RN on 07/02/20 at 4:13 a.m. No further nursing documentation by a RN was noted.

2. A review was conducted of the facility's policy "Hospital Plan for Provision of Care, PCM-SPP-0082," last review date 02/2019. It states in part under section "Department of Nursing. 8. Primary Position Descriptions: B. Registered Nurse 1. ...the prime role of the Registered Nurse is the execution of the nursing process in prescribing care required, assessing, planning, implementing, and evaluation effectiveness of care given. The registered Nurse reviews and analyzes data collected, revises the plan of care, and assumes responsibility for decisions regarding professional skills and judgement. C. Licensed Practical Nurse 1. The Licensed Practical Nurse (LPN) works under the supervision of the Registered Nurse in carrying out the nursing process. The LPN assumes responsibility for a full patient assignment for a shift of duty, and works under the direct supervision of the RN ....The LPN seeks direction and validation from the RN frequently throughout the shift, and interacts with patients, significant others, physicians, and support service members in concert with, and as directed by, the responsible RN."

3. The hand-written staffing assignments were reviewed for Unit Two (2) North from 07/01/20 through 07/04/20, both day shift and night shift. Patient #1 was assigned to staff listed as LPNs each shift until he was discharged.

4. A telephone interview was conducted with the Director of Two (2) North on 08/25/20 at 8:57 a.m. When asked about patient assignments on his unit, he stated, "The RN is responsible for all care on their end of the hallway. Typically, if an LPN is assigned a set of patients on one shift, the next shift an RN would be assigned. It rotates back and forth so an RN is caring for the patient sometime within a twenty-four (24) hours. I'm not sure what had happened with (patient #1) being assigned an LPN each shift on each day he was here."

5. A telephone interview was conducted with RN #2 on 08/25/20 at 9:46 a.m. She discussed that sometimes she was relief charge nurse and makes nursing assignments for night shift. She stated, "I try to alternate, LPN and RN, so there is a RN next to each LPN. We call them RN 'buddies.' The RNs do not review the LPN documentation or get report on the LPNs patients. The LPNs take care of their own patients."

6. A telephone interview was conducted with the Charge nurse of Two (2) North on 08/25/20 at 11:49 a.m. Regarding assignments on her unit, she stated, "Each LPN has a RN 'buddy' who can help them with their patients if they need something. The RN does not receive report on the LPNs patients and only would see them if the LPN asked. The RN does not review the LPNs charting to see if everything is done. The RN does not verify if the LPN is following the plan of care. I was never told we were responsible for any LPNs patients. The LPNs are in charge of their own patients."

7. A telephone interview was conducted with RN #3 on 08/25/20 at 12:14 p.m. Regarding assignments on her unit, she stated, "I was never told I was responsible for the LPNs patients. If the LPN has a problem with their patient, they come to us or the charge nurse, and we would help. We do not take over care of their patient if there is a problem. We do not review their documentation to ensure care was completed. We don't receive report on their patients."

8. A telephone interview was conducted with the Director of Two (2) North on 08/25/20 at 12:33 p.m. He stated, "The RN is supposed to sign off on all LPN assessments each shift. I'm not sure why or when this has stopped."

9. A telephone interview was conducted with the Director of Nursing on 08/25/20 at 1:23 p.m. She stated, "My expectation is that the RN would review the LPNs documentation, at least once in a twenty-four (24) hour period. I do not know what happened on that unit (Two (2) North). It will be fixed and fixed today."

Based on medical record review, document review and interviews it was revealed the facility failed to provide oral care to a one (1) out of thirty (30) patients (patient #1). This failure has the potential to negatively impact all patients who need assistance with oral care.

Findings include:

1. A review was conducted of patient #1's medical record on 08/24/20. The patient was admitted to the Telemetry Unit, Two (2) North, with a diagnosis of cerebrovascular accident (CVA). The patient was ordered nothing by mouth (NPO) which continued until discharge. Oral care was documented by a LPN (LPN #1) on 07/02/20 at 9:36 a.m. with a nursing note stating she took "toothettes" to the patient. Oral care was again charted by a patient care assistant (PCA) on 07/02/20 at 8:53 p.m. No further documentation of oral care was noted.

2. A review was conducted of facility policy "Oral Care Protocol" with last revised date 04/2019. It states in part: "For General Oral Care: A. 2. If NPO, document a minimum of 4 times daily."

3. A telephone interview was conducted with LPN #1 on 08/24/20 at 3:39 p.m. The nurse remembered patient #1. She stated, "I gave him toothettes, which is a mouth swab with mouthwash, lemon or plain. I set them up in a cup of water and helped the patient do it the first time but he was able to do it himself after that."

4. A telephone interview was conducted with LPN #2 on 08/24/20 at 4:00 p.m. He stated, "The patient had mouth swabs given to him for oral care but couldn't do that himself, he needed assistance. I did provide the oral care myself several times."

5. A telephone interview was conducted with LPN #3 on 08/25/20 at 7:42 a.m. She recalled patient #1. She stated, "We gave him swabs to do his own oral care. We do not document anywhere when oral care is done."

6. A telephone interview was conducted with the PCA on 08/25/20 at 7:55 a.m. She did not remember patient #1. Regarding patients receiving oral care she stated, "We swab the patients that need assistance every two hours when we check on the patients with our regular rounding. We do not chart this anywhere."

7. A telephone interview was conducted with the Director of Two (2) North on 08/25/20 at 8:57 a.m. Regarding oral care for patients he stated, "It is policy to document oral care. It is obvious and easy to see where it needs to be documented in the medical record."

Based on review of documents, medical records and staff interviews, the facility failed to provide nursing services supervised by a Registered Nurse (RN), see tag A 393, failed to ensure an RN supervised and evaluated the care provided to patients, see tag A 395, failed to ensure nursing care plans were kept current, see tag A 396 and failed to ensure adequate supervision and evaluation of all nursing personnel by not ensuring RN review of LPNs documentation and following of policy and procedures, see tag A 398.

Based on record review, document review and interviews it was revealed the facility failed to provide nursing services supervised by a Registered Nurse in one (1) out of thirty (30) patients. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

1. A review of patient #1 medical record revealed an admission assessment was documented by a Registered Nurse (RN#1) on 07/01/20 at 8:34 p.m. A Nursing Care plan was initiated by RN #1 on 07/01/20 at 8:40 p.m. A limited assessment was conducted by a different RN on 07/02/20 at 4:13 a.m. No further nursing documentation by a RN was noted.

2. A review was conducted of the facility's policy "Hospital Plan for Provision of Care, PCM-SPP-0082," last review date 02/2019. It states in part under section "Department of Nursing. 8. Primary Position Descriptions: B. Registered Nurse 1. ...the prime role of the Registered Nurse is the execution of the nursing process in prescribing care required, assessing, planning, implementing, and evaluation effectiveness of care given. The registered Nurse reviews and analyzes data collected, revises the plan of care, and assumes responsibility for decisions regarding professional skills and judgement. C. Licensed Practical Nurse 1. The Licensed Practical Nurse (LPN) works under the supervision of the Registered Nurse in carrying out the nursing process. The LPN assumes responsibility for a full patient assignment for a shift of duty, and works under the direct supervision of the RN ....The LPN seeks direction and validation from the RN frequently throughout the shift, and interacts with patients, significant others, physicians, and support service members in concert with, and as directed by, the responsible RN."

3. The hand-written staffing assignments were reviewed for Unit Two (2) North from 07/01/20 through 07/04/20, both day shift and night shift. Patient #1 was assigned to staff listed as LPNs each shift until he was discharged.

4. A telephone interview was conducted with the Director of Two (2) North on 08/25/20 at 8:57 a.m. When asked about patient assignments on his unit, he stated, "The RN is responsible for all care on their end of the hallway. Typically, if an LPN is assigned a set of patients on one shift, the next shift an RN would be assigned. It rotates back and forth so an RN is caring for the patient sometime within a twenty-four (24) hours. I'm not sure what had happened with (patient #1) being assigned an LPN each shift on each day he was here."

5. A telephone interview was conducted with RN #2 on 08/25/20 at 9:46 a.m. She discussed that sometimes she was relief charge nurse and makes nursing assignments for night shift. She stated, "I try to alternate, LPN and RN, so there is a RN next to each LPN. We call them RN 'buddies.' The RNs do not review the LPN documentation or get report on the LPNs patients. The LPNs take care of their own patients."

6. A telephone interview was conducted with the Charge nurse of Two (2) North on 08/25/20 at 11:49 a.m. Regarding assignments on her unit, she stated, "Each LPN has a RN 'buddy' who can help them with their patients if they need something. The RN does not receive report on the LPNs patients and only would see them if the LPN asked. The RN does not review the LPNs charting to see if everything is done. The RN does not verify if the LPN is following the plan of care. I was never told we were responsible for any LPNs patients. The LPNs are in charge of their own patients."

7. A telephone interview was conducted with RN #3 on 08/25/20 at 12:14 p.m. Regarding assignments on her unit, she stated, "I was never told I was responsible for the LPNs patients. If the LPN has a problem with their patient, they come to us or the charge nurse, and we would help. We do not take over care of their patient if there is a problem. We do not review their documentation to ensure care was completed. We don't receive report on their patients."

8. A telephone interview was conducted with the Director of Two (2) North on 08/25/20 at 12:33 p.m. He stated, "The RN is supposed to sign off on all LPN assessments each shift. I'm not sure why or when this has stopped."

9. A telephone interview was conducted with the Director of Nursing on 08/25/20 at 1:23 p.m. She stated, "My expectation is that the RN would review the LPNs documentation, at least once in a twenty-four (24) hour period. I do not know what happened on that unit (Two (2) North). It will be fixed and fixed today."

Based on record review, document review and interviews it was revealed the facility failed to ensure a Registered Nurse (RN) supervised and evaluated the care provided in one (1) out of thirty (30) patients. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

1. A review of patient #1 medical record revealed an admission assessment was documented by a Registered Nurse (RN#1) on 07/01/20 at 8:34 p.m. A Nursing Care plan was initiated by RN #1 on 07/01/20 at 8:40 p.m. A limited assessment was conducted by a different RN on 07/02/20 at 4:13 a.m. No further nursing documentation by a RN was noted.

2. A review was conducted of the facility's policy "Hospital Plan for Provision of Care, PCM-SPP-0082," last review date 02/2019. It states in part under section "Department of Nursing. 8. Primary Position Descriptions: B. Registered Nurse 1. ...the prime role of the Registered Nurse is the execution of the nursing process in prescribing care required, assessing, planning, implementing, and evaluation effectiveness of care given. The registered Nurse reviews and analyzes data collected, revises the plan of care, and assumes responsibility for decisions regarding professional skills and judgement. C. Licensed Practical Nurse 1. The Licensed Practical Nurse (LPN) works under the supervision of the Registered Nurse in carrying out the nursing process. The LPN assumes responsibility for a full patient assignment for a shift of duty, and works under the direct supervision of the RN ....The LPN seeks direction and validation from the RN frequently throughout the shift, and interacts with patients, significant others, physicians, and support service members in concert with, and as directed by, the responsible RN."

3. The hand-written staffing assignments were reviewed for Unit Two (2) North from 07/01/20 through 07/04/20, both day shift and night shift. Patient #1 was assigned to staff listed as LPNs each shift until he was discharged.

4. A telephone interview was conducted with the Director of Two (2) North on 08/25/20 at 8:57 a.m. When asked about patient assignments on his unit, he stated, "The RN is responsible for all care on their end of the hallway. Typically, if an LPN is assigned a set of patients on one shift, the next shift an RN would be assigned. It rotates back and forth so an RN is caring for the patient sometime within a twenty-four (24) hours. I'm not sure what had happened with (patient #1) being assigned an LPN each shift on each day he was here."

5. A telephone interview was conducted with RN #2 on 08/25/20 at 9:46 a.m. She discussed that sometimes she was relief charge nurse and makes nursing assignments for night shift. She stated, "I try to alternate, LPN and RN, so there is a RN next to each LPN. We call them RN 'buddies.' The RNs do not review the LPN documentation or get report on the LPNs patients. The LPNs take care of their own patients."

6. A telephone interview was conducted with the Charge nurse of Two (2) North on 08/25/20 at 11:49 a.m. Regarding assignments on her unit, she stated, "Each LPN has a RN 'buddy' who can help them with their patients if they need something. The RN does not receive report on the LPNs patients and only would see them if the LPN asked. The RN does not review the LPNs charting to see if everything is done. The RN does not verify if the LPN is following the plan of care. I was never told we were responsible for any LPNs patients. The LPNs are in charge of their own patients."

7. A telephone interview was conducted with RN #3 on 08/25/20 at 12:14 p.m. Regarding assignments on her unit, she stated, "I was never told I was responsible for the LPNs patients. If the LPN has a problem with their patient, they come to us or the charge nurse, and we would help. We do not take over care of their patient if there is a problem. We do not review their documentation to ensure care was completed. We don't receive report on their patients."

8. A telephone interview was conducted with the Director of Two (2) North on 08/25/20 at 12:33 p.m. He stated, "The RN is supposed to sign off on all LPN assessments each shift. I'm not sure why or when this has stopped."

9. A telephone interview was conducted with the Director of Nursing on 08/25/20 at 1:23 p.m. She stated, "My expectation is that the RN would review the LPNs documentation, at least once in a twenty-four (24) hour period. I do not know what happened on that unit (Two (2) North). It will be fixed and fixed today."

Based on record review, document review and interviews it was revealed the facility failed to ensure a nursing care plan was kept current in one (1) out of thirty (30) patients. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

1. A review of patient #1 medical record revealed an admission assessment was documented by a Registered Nurse (RN#1) on 07/01/20 at 8:34 p.m. A Nursing Care plan was initiated by RN #1 on 07/01/20 at 8:40 p.m. A limited assessment was conducted by a different RN on 07/02/20 at 4:13 a.m. No further nursing documentation by a RN was noted.

2. A review was conducted of the facility's policy "Hospital Plan for Provision of Care, PCM-SPP-0082," last review date 02/2019. It states in part under section "Department of Nursing. 8. Primary Position Descriptions: B. Registered Nurse 1. ...the prime role of the Registered Nurse is the execution of the nursing process in prescribing care required, assessing, planning, implementing, and evaluation effectiveness of care given. The registered Nurse reviews and analyzes data collected, revises the plan of care, and assumes responsibility for decisions regarding professional skills and judgement. C. Licensed Practical Nurse 1. The Licensed Practical Nurse (LPN) works under the supervision of the Registered Nurse in carrying out the nursing process. The LPN assumes responsibility for a full patient assignment for a shift of duty, and works under the direct supervision of the RN ....The LPN seeks direction and validation from the RN frequently throughout the shift, and interacts with patients, significant others, physicians, and support service members in concert with, and as directed by, the responsible RN."

3. The hand-written staffing assignments were reviewed for Unit Two (2) North from 07/01/20 through 07/04/20, both day shift and night shift. Patient #1 was assigned to staff listed as LPNs each shift until he was discharged.

4. A telephone interview was conducted with the Director of Two (2) North on 08/25/20 at 8:57 a.m. When asked about patient assignments on his unit, he stated, "The RN is responsible for all care on their end of the hallway. Typically, if an LPN is assigned a set of patients on one shift, the next shift an RN would be assigned. It rotates back and forth so an RN is caring for the patient sometime within a twenty-four (24) hours. I'm not sure what had happened with (patient #1) being assigned an LPN each shift on each day he was here."

5. A telephone interview was conducted with RN #2 on 08/25/20 at 9:46 a.m. She discussed that sometimes she was relief charge nurse and makes nursing assignments for night shift. She stated, "I try to alternate, LPN and RN, so there is a RN next to each LPN. We call them RN 'buddies.' The RNs do not review the LPN documentation or get report on the LPNs patients. The LPNs take care of their own patients."

6. A telephone interview was conducted with the Charge nurse of Two (2) North on 08/25/20 at 11:49 a.m. Regarding assignments on her unit, she stated, "Each LPN has a RN 'buddy' who can help them with their patients if they need something. The RN does not receive report on the LPNs patients and only would see them if the LPN asked. The RN does not review the LPNs charting to see if everything is done. The RN does not verify if the LPN is following the plan of care. I was never told we were responsible for any LPNs patients. The LPNs are in charge of their own patients."

7. A telephone interview was conducted with RN #3 on 08/25/20 at 12:14 p.m. Regarding assignments on her unit, she stated, "I was never told I was responsible for the LPNs patients. If the LPN has a problem with their patient, they come to us or the charge nurse, and we would help. We do not take over care of their patient if there is a problem. We do not review their documentation to ensure care was completed. We don't receive report on their patients."

8. A telephone interview was conducted with the Director of Two (2) North on 08/25/20 at 12:33 p.m. He stated, "The RN is supposed to sign off on all LPN assessments each shift. I'm not sure why or when this has stopped."

9. A telephone interview was conducted with the Director of Nursing on 08/25/20 at 1:23 p.m. She stated, "My expectation is that the RN would review the LPNs documentation, at least once in a twenty-four (24) hour period. I do not know what happened on that unit (Two (2) North). It will be fixed and fixed today."

Based on record review, document review and interviews it was revealed the facility failed to ensure the nurses adhered to the policies and procedures of the hospital in one (1) out of thirty (30) patients. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

1. A review of patient #1 medical record revealed an admission assessment was documented by a Registered Nurse (RN#1) on 07/01/20 at 8:34 p.m. A Nursing Care plan was initiated by RN #1 on 07/01/20 at 8:40 p.m. A limited assessment was conducted by a different RN on 07/02/20 at 4:13 a.m. No further nursing documentation by a RN was noted.

2. A review was conducted of the facility's policy "Hospital Plan for Provision of Care, PCM-SPP-0082," last review date 02/2019. It states in part under section "Department of Nursing. 8. Primary Position Descriptions: B. Registered Nurse 1. ...the prime role of the Registered Nurse is the execution of the nursing process in prescribing care required, assessing, planning, implementing, and evaluation effectiveness of care given. The registered Nurse reviews and analyzes data collected, revises the plan of care, and assumes responsibility for decisions regarding professional skills and judgement. C. Licensed Practical Nurse 1. The Licensed Practical Nurse (LPN) works under the supervision of the Registered Nurse in carrying out the nursing process. The LPN assumes responsibility for a full patient assignment for a shift of duty, and works under the direct supervision of the RN ....The LPN seeks direction and validation from the RN frequently throughout the shift, and interacts with patients, significant others, physicians, and support service members in concert with, and as directed by, the responsible RN."

3. The hand-written staffing assignments were reviewed for Unit Two (2) North from 07/01/20 through 07/04/20, both day shift and night shift. Patient #1 was assigned to staff listed as LPNs each shift until he was discharged.

4. A telephone interview was conducted with the Director of Two (2) North on 08/25/20 at 8:57 a.m. When asked about patient assignments on his unit, he stated, "The RN is responsible for all care on their end of the hallway. Typically, if an LPN is assigned a set of patients on one shift, the next shift an RN would be assigned. It rotates back and forth so an RN is caring for the patient sometime within a twenty-four (24) hours. I'm not sure what had happened with (patient #1) being assigned an LPN each shift on each day he was here."

5. A telephone interview was conducted with RN #2 on 08/25/20 at 9:46 a.m. She discussed that sometimes she was relief charge nurse and makes nursing assignments for night shift. She stated, "I try to alternate, LPN and RN, so there is a RN next to each LPN. We call them RN 'buddies.' The RNs do not review the LPN documentation or get report on the LPNs patients. The LPNs take care of their own patients."

6. A telephone interview was conducted with the Charge nurse of Two (2) North on 08/25/20 at 11:49 a.m. Regarding assignments on her unit, she stated, "Each LPN has a RN 'buddy' who can help them with their patients if they need something. The RN does not receive report on the LPNs patients and only would see them if the LPN asked. The RN does not review the LPNs charting to see if everything is done. The RN does not verify if the LPN is following the plan of care. I was never told we were responsible for any LPNs patients. The LPNs are in charge of their own patients."

7. A telephone interview was conducted with RN #3 on 08/25/20 at 12:14 p.m. Regarding assignments on her unit, she stated, "I was never told I was responsible for the LPNs patients. If the LPN has a problem with their patient, they come to us or the charge nurse, and we would help. We do not take over care of their patient if there is a problem. We do not review their documentation to ensure care was completed. We don't receive report on their patients."

8. A telephone interview was conducted with the Director of Two (2) North on 08/25/20 at 12:33 p.m. He stated, "The RN is supposed to sign off on all LPN assessments each shift. I'm not sure why or when this has stopped."

9. A telephone interview was conducted with the Director of Nursing on 08/25/20 at 1:23 p.m. She stated, "My expectation is that the RN would review the LPNs documentation, at least once in a twenty-four (24) hour period. I do not know what happened on that unit (Two (2) North). It will be fixed and fixed today."