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Based on record review and interview, the facility failed to ensure a registered nurse evaluated the nursing care for each patient, in that, 1 of 1 patients (Patient #1) did not have complete reassessments by a registered nurse conducted every 12 hours.

Findings included:

Patient #1 was admitted to the facility on 3/15/2023 with agitation and aggressive behaviors.

A review of the medical record for Patient #1 revealed the facility's Daily Nursing Assessment, performed every 12 hours, listed the following areas to be assessed:

*Appearance
*Behavior
*Speech
*Orientation
*Medication
*Sleep
*Appetite
*Bowel Movement
*Elimination
*Intellectual Functioning
*Thought Content
*Affect
*Precautions
*Was prior CSSRS (Columbia Suicide Severity Rating Scale) Score Moderate or High
*Patient experiencing pain
*PRN (as needed) Medication Reassessment
*Nursing Intervention
*Patient Motivation Toward Treatment
*Respiratory
*Cardiovascular
*Neuromuscular
*Gastrointestinal
*Urinary

A review of Daily Nursing Assessments during Patient #1's admission revealed the following:

1. 3/15/2023 night shift-respiratory not assessed.
2. 3/16/2023 day shift-respiratory and cardiovascular not assessed.
3. 3/17/2023 day shift- respiratory and cardiovascular not assessed.
4. 3/18/2023 day shift- respiratory and cardiovascular not assessed.
5. 3/20/2023 day shift-respiratory and cardiovascular not assessed.
6. 3/21/2023 night shift-cardiovascular not assessed.
7. 3/21/2023 day shift-respiratory and cardiovascular not assessed.
8. 3/22/2023 night shift-cardiovascular not assessed.
9. 3/22/2023 day shift-respiratory not assessed.
10. 3/23/2023 night-respiratory and cardiovascular not assessed.
11. 3/26/2023 night shift-respiratory not assessed.
12. 3/27/2023 night shift-respiratory and cardiovascular not assessed.

Of the Daily Nursing Assessments, 12 of 23 performed were incomplete regarding the areas to be addressed using the nursing assessment template.

During an interview with Personnel #3 on 5/18/2023, Personnel #3 confirmed that the Daily Nursing Assessments were not appropriately completed every 12 hours. Personnel #3 stated that the nursing skin assessment is not part of the standard nursing assessment template, and any findings are documented in the Nursing Progress Notes and/or in the daily Braden Risk Assessment.

The Wellbridge Healthcare of Greater Dallas policy titled "Interdisciplinary Assessment and Reassessment" effective 1/2022 required, " ...Patients are re-evaluated by an RN (registered nurse) at a minimum every 12-hour shift-based on level of care and patient care needs ...Patient reassessment is completed: i. To evaluate patient response to care, treatment, and services; ii. To respond to a significant change in status and/or diagnosis or condition ...All nursing assessment(s)/reassessments are recorded in the patient medical record by the RN ..."