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A. Based on a review of Hospital policy and procedure, medical record review, and staff interview, it was determined that in 2 of 13 (Pts #4, #13) medical records reviewed for nursing admission assessments, the admission charting was not completed within the required time frames.

Findings include:

1. The Hospital policy and procedure titled, "Subject: Nursing Process" Directive Number 8751-32, with an Effective Date February 8, 2007, was reviewed on 8/9/12. It indicated under, "II. NURSING PROCESS A. ASSESSMENT 3. Admission Assessment: Assessment begins with the initial contact with patient and/or family. Data collection is obtained through interview, observation and examination by the registered professional nurse, ...The patient's health history is recorded on the Admission Patient Profile...or a similar unit specific nursing history form is completed within twenty four hours of admission. The physical assessment is recorded on the Routine Nursing Assessment flow sheet or similar unit-specific assessment form within 12 hours of admission or per unit standard...."

2. The medical record of Pt #4 was reviewed on 8/9/12. It indicated that Pt #4 was admitted to the Labor and Delivery Unit on 7/30/12. Documentation indicated that the nursing admission assessment was not completed as of survey date 8/9/12.

3. The medical record of Pt #13 was reviewed on 8/9/12. It indicated that Pt #13 was admitted to the Labor and Delivery Unit on 7/7/12. Documentation indicated that the nursing admission assessment was not completed as of survey date 8/9/12.

4. During an interview with the Birth Center Nurse Manager, it was verbalized that the nursing admission charting should have been completed with the guidelines of the policy and procedure. It was further stated that, in most circumstances, registered nurses do not leave the unit at the end of shift until all their charting is complete.