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Based on record review and interview the facility failed to follow their policies and procedures to ensure patient care was provided by staff as ordered in the medical record in 5 of 10 postoperative patients (Patient #1, #2, #6, #7 and #8) in a total of 10 medical records reviewed.

Findings include:

Review of policy "Nursing Patient Assessment, Documentation, Care Planning, Learning Assessment and Patient Education" last reviewed 2/19/2021 under Policy, B. "The RN is responsible for the documentation of a nursing assessment... A full Patient Assessment will be performed and documented: 1. When receiving a patient upon admission or transfer from one level of care to another."

Review of "Standards of Practice for Reduced Registered Nursing Documentation during Phase III and IV of COVID Surge Plan" updated 8/20/2021 under Requirements for assessments, reassessments, and nursing documentation, Initial Inpatient Admission revealed " Documentation of the following is required with initial assessment following admission: Vital signs: Temp, Pulse/Heart Rate, Respiratory Rate, BP, and SpO2." Under Frequency of Assessments/Reassessments Medical/Surgical revealed "Minimum assessment/reassessment of once per shift."

Review of policy "Medication Management, Administration and Documentation" #C01.069, not dated, under Medication Documentation #6 revealed "For all "PRN" (as needed) medications, administration justification will be documented in the EHR" (electronic health record).

On 2/15/2022 at 1:40 PM Patient #1's medical record was reviewed and revealed Patient #1 is a 30- year-old admitted 1/27/2022 for a DIEP (deep inferior epigastric perforator) Flap with explantation of breast implants (tissue taken from the abdomen to replace breast implants). Post operative orders dated 1/27/2022 at 5:02 PM for vital signs revealed "On arrival and every 15 minutes X1, then every 1 hour X6" for nausea revealed "ondansetron... q 8 hours prn" (every 8 hours as needed) . Patient #1 arrived to the Surgical floor on 1/27/2022 at 5:09 PM and vital signs were taken. There were no vital signs documented again until 7:07 PM, 2 hours after arrival to the floor. Ondansetron 4 mg (for nausea) was given intravenously at 6:25 PM. There was no documentation of Patient #1 being nauseated. The first nursing assessment was not documented until the next shift, on 1/28/2022 at 4:01 AM.

On 2/15/2022 at 1:40 PM during interview with Clinical Nurse Specialist (CNS) Q while reviewing the vital signs in Patient #1's medical record, CNS Q stated "that's all I see."

On 2/16/2022 at 10:28 AM during interview with Assistant Nurse Manager (ANM) F, when asked what the expectation for documentation of nausea is when a nausea medication is administered, ANM F stated nausea should be documented under the gastrointestinal section stating it's "something we need to work on."

On 2/15/2022 at 3:31 PM Patient #2's medical record was reviewed and revealed Patient #2 is a 62- year-old who presented to the Emergency Department 1/25/22 with abdominal pain and a history of a gastric bypass, underwent an emergent diagnostic scope under general anesthesia on 1/25/2022 and was transferred to PACU (Post Anesthesia Care Unit) on 1/25/2022 at 5:36 PM. Post operative orders dated 1/15/2022 at 5:58 PM revealed vital signs "Every 15 minutes Until Specified". Patient #2 was in holding area in PACU until they arrived to the Surgical floor 1/25/2022 at 7:14 PM when vital signs were taken . Post-operative order for vital signs 1/25/2022 at 7:18 PM revealed frequency "Every 4 hours." There were no vital signs documented from 5:36 PM until 7:29 PM, 3 hours and 20 minutes after the first set of post operative vital signs were taken.

On 2/15/2022 at 3:31 PM during interview with Clinical Nurse Specialist (CNS) Q while reviewing the vital signs in Patient #2's medical record, CNS Q stated "that's all I see."

On 2/16/2022 at 12:31 PM Patient #6's medical record was reviewed and revealed Patient #6 was a 32- year-old admitted 2/04/2022 for left breast reconstruction with a flap. Post operative orders dated 2/04/2022 at 4:09 PM for vital signs revealed "q1hr X 1" (every hour X 1). Patient #6 arrived on the Surgical floor on 2/04/2022 at 4:09 PM and vital signs were taken. There were no vital signs documented again until 7:29 PM, 3 hours and 20 minutes after the first set of vital signs were taken.

On 2/16/2022 at 12:31 PM during interview with Clinical Nurse Specialist (CNS) Q while reviewing the vital signs in Patient #6's medical record, CNS Q stated "that's all I see."

On 2/16/2022 at 12:43 PM Patient #7's medical record was reviewed and revealed Patient #7 was a 60-year-old admitted 2/06/2022 for exchange of bilateral tissue expanders with silicone implants. Patient #7 arrived to the Surgical floor on 2/06/2022 at 7:07 PM. The first nursing assessment was not documented until the next shift on 2/08/2022 at 8:14 AM.

On 2/16/2022 at 12:43 PM during interview with Clinical Nurse Specialist (CNS) Q, while looking for the nursing assessments in Patient #7's medical record, CNS Q stated "12 hours went by, there should be something" and confirmed there was no admission assessment documented earlier.

On 2/17/2022 at 10:18 AM Patient #8's medical record was reviewed and revealed Patient #8 was a 44- year-old admitted 2/14/2022 for a gastric bypass. Post operative vital sign orders dated 2/14/2022 at 12:31 PM revealed "q (every) 15 minutes until stable, q 1 hr X4, q 4 hr X 24." Patient #8 arrived to the Surgical floor on 2/14/2022 at 1:42 PM. The first vitals signs were taken at 2:59 PM (1 hour and 17 minutes after arrival to the Surgical Unit) and were stable. Only 3 of 4 vital signs were taken over the next 4 hours.

On 2/17/2022 at 10:18 AM during interview with Quality Coordinator (QC) E, while while reviewing the vital signs in Patient #8's medical record, QC E stated "it looks like one is missing" and confirmed the vital signs were not taken when Patient #8 arrived on the Surgical Unit at 1:42 PM.

Based on record review and interview the facility failed to ensure a complete post-anesthesia evaluation was completed by an individual qualified to administer anesthesia according to their policies and procedures in 2 of 10 post-operative patients (Patient #3 & #5) in a total of 10 medical records reviewed.

Findings include:

Record review of policy "Anesthesia Post Operative Assessments" #ANT-006, not dated, under Procedure revealed "May be done any time after the patient is sufficiently recovered from the acute administration of the anesthesia so as to participate in the evaluation."

Patient #3's medical record revealed Patient #3 underwent bilateral breast mastectomy with reconstruction under general anesthesia on 1/21/2022. Anesthesia started 1/21/2022 at 8:50 AM and ended at 3:37 PM. Immediate Post-Anesthesia Care Note dated 1/21/2022 at 3:37 PM under Anesthesia Post Evaluation under This patient has sufficiently recovered from the effect of anesthesia and is able to participate in the post anesthesia evaluation revealed "No-unable to participate, sedation." Under mental Status: Level of consciousness revealed "sedated." Patient #3 was transported to the Surgical floor on 1/21/2022 at 5:20 PM. There was no other post anesthesia note completed by an individual qualified to administer anesthesia.

Patient #5's medical record revealed Patient #5 underwent breast reconstruction under general anesthesia on on 1/31/2021. Anesthesia started 1/31/2022 at 9:03 AM and ended at 5:03 PM. Immediate Post-Anesthesia Care Note dated 1/31/2022 at 5:05 PM, Anesthesia Post Evaluation under This patient has sufficiently recovered from the effect of anesthesia and is able to participate in the post anesthesia evaluation revealed "No-unable to participate, sedation." Under mental Status: Level of consciousness revealed "sedated" under Orientation "Not orientated." Patient #5 was transported to the Surgical floor on 1/31/2022 at 6:20 PM. There was no other post anesthesia note.

On 2/17/2022 at 10:08 AM during medical record review of Patient #3 and Patient #5's post anesthesia evaluations with Quality Coordinator (QC) E and Patient Safety Specialist D, QC E confirmed there were no other post anesthesia evaluations completed by an individual qualified to administer anesthesia.

On 2/17/2022 at 10:08 AM during interview with Chief Certified Registered Nurse Anesthetist (CRNA) R when shown the policy "Anesthesia Post Operative Assessment" and asked if a post-operative assessment can be performed on a patient that cannot participate in the post-operative evaluation, CRNA R stated "that's what the Recovery Room is for."