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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES, was out of compliance.

A-0395 RN SUPERVISION OF NURSING CARE A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews, document review and record review, the facility failed to assess patients in accordance with facility policy in 4 of 4 medical records (Patients #1, #2, #3 and #4). Specifically, nursing staff failed to complete nursing admission assessments for patients upon admission to the facility.

Based on interviews, document review and record review, the facility failed to assess patients in accordance with facility policy in 4 of 4 medical records (Patients #1, #2, #3 and #4). Specifically, nursing staff failed to complete nursing admission assessments for patients upon admission to the facility.

Findings include:

Facility policies:

According to the policy titled Assessment and Diagnosis dated 9/7/11, a registered nurse will perform admission assessments at the time patients were admitted to the facility. The nursing assessment will document the patient's mental status, medical condition, vital signs, skin integrity, recent hospitalizations, physical limitations or disabilities, self-disclosed substance use, dietary needs or restrictions, active medications and patient allergies.

According to the policy titled Admission Process dated 9/7/11, the nursing admission assessment must be completed for each patient upon admission to the facility.

1. The facility failed to ensure nursing admission assessments were performed at the time of patient admission.

a. According to the facility policies, the nursing admission assessment must be completed for each patient upon admission to the facility.

b. A review of patient records revealed from 10/20/20 to 4/16/21 patient records lacked nursing admission assessments at the time of admission. Furthermore, record review revealed delayed completion of the nursing admission assessment impacted patient care and safety. Examples include:

i. Record review of Patient #1 revealed the patient had a diagnosis of a recent suicide attempt and self-injurious behaviors when she was admitted to the facility on 12/29/20 at 12:25 a.m. Record review revealed the nursing admission assessment documentation was completed on 1/1/21 at 10:40 p.m., approximately three days and 22 hours after the patient had been admitted to the facility.

Subsequently, record review revealed Patient #1 was involved in an adverse event at the facility. At the time of the event Patient #1's actions were impulsive and intrusive. Patient #1 was physically injured during the event. Patient #1 experienced escalated thoughts of self-harm and increased anxiety following the adverse event. The adverse event occurred on 12/29/20 at 9:27 p.m., nine hours after the patient was admitted to the facility and two days and 14 hours before the nursing admission assessment was completed.

ii. Record review of Patient #3 revealed the patient had a diagnosis of suicidal ideation with an active plan to commit suicide when he was admitted to the facility on 4/14/21 at 1:00 a.m. Record review revealed the nursing admission assessment documentation was completed on 4/16/21 at 6:37 p.m., approximately two days and 17 hours after the patient had been admitted to the facility.

iii. Record review of Patient #4 revealed the patient had a diagnosis of suicidal ideation with concurrent substance abuse when he was admitted to the facility on 10/20/20 at 3:15 p.m. Review revealed the nursing admission assessment documentation was completed on 10/22/20 at 12:14 p.m., approximately one day and 20 hours after the patient had been admitted to the facility.

iv. Record review of Patient #2 revealed the patient had a diagnosis of a recent suicide attempt, suicidal ideation and in self-injurious behaviors when she was admitted to the facility on 3/5/21 at 4:15 p.m. Record review revealed the nursing admission assessment was not performed by the day shift nurse at the time of admission. The nursing admission assessment was completed by the night shift by the night nurse at 11:15 p.m., approximately seven hours after the patient had been admitted to the facility.

This was in contrast with the facility policy which stated nursing admission assessments must be completed for each patient upon admission to the facility.

c. Interviews with staff revealed nursing admission assessments were to be completed and documented in the patient medical record no more than 24 hours after the patient had been admitted. These interviews were in contrast to facility policies which stated the nursing admission assessment must be completed for each patient upon admission to the facility.

i. On 6/2/21 at 3:06 p.m., an interview was conducted with Admission Intake Registered Nurse (Admit RN) #4. Admit RN #4 stated nursing admission assessments were completed by the inpatient nurse, once the patient had been admitted to the facility and placed on a unit.

Admit RN #4 stated nursing admission assessments were important to complete. She stated medical concerns and health conditions were reviewed during the nursing admission assessments. Admit RN #4 stated nursing admission assessments provided information about behavioral triggers, eliminated potential gaps in patient care and reviewed the overall needs of patients.

ii. On 6/2/21 at 2:25 p.m., an interview was conducted with the Director of Nursing (DON) #5. DON #5 stated per facility policy nursing admission assessments were to be performed within 24 hours of admission.

DON #5 stated nursing admission assessments provided information about past medical history, overview of chronic health conditions and review of behavioral health concerns. DON #5 stated incomplete or absent nursing admission assessments placed the patient at risk for delayed medical treatment and impeded behavioral therapy progress.

iii. On 6/2/21 at 10:62 a.m., an interview was conducted with Registered Nurse (RN) #2. RN #2 stated the nursing admission assessment was expected to be performed within 24 hours of the patient being admitted to the facility. RN #2 stated the nursing admission assessment did not need to be completed by the nurse who admitted the patient.

RN #2 stated completion of the nursing admission assessment assisted to identify patient coping mechanisms and potential triggers for adverse behavior. RN #2 stated when nursing admission assessments were not performed the patient was at risk of mis-management and treatment of medical conditions.

iv. On 6/2/21 at 8:03 p.m., an interview was conducted with RN #3. RN #3 stated nursing admission assessments were completed by the inpatient RN. RN #3 stated nursing admission assessments did not have to be performed during the nursing shift the patient was admitted on. RN #3 stated nursing admission assessments not performed during the prior nursing shift became the responsibility of the oncoming nurse.

RN #3 stated nurses were instructed to perform the nursing admission assessment within 24 hours of the patient admission. RN #3 stated there was potential for patient harm when nursing admission assessments were not performed. RN #3 stated mis-management of chronic health conditions, behavioral triggers and medical emergencies could occur when the nursing admission assessments have not been performed.

These interviews were in contrast with facility policy which stated admission assessments would be performed at the time of admission to the facility.