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Based on record review and interview, the facility failed to ensure in advance of furnishing patient care, each patient was informed of their patient rights including a process for filing a complaint, or, if appropriate, from the patient's parent, managing conservator, or guardian, in that, 10 of 10 patient's (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) medical record did not document a signed copy of the patient's bill of rights from each patient.

Findings included

Patient #1's, #2's, #3's, #4's, #5's, #6's, #7's, #8's, #9's, and #10's medical record did not document a signed copy of the patient's bill of rights from each patient.

During an interview on 2/13/18 ending at 1:28 PM, Personnel #2 was informed of the above findings. Personnel #2 reviewed each and confirmed the findings.

Based on record review and interview, the facility failed to ensure a registered nurse (RN) evaluated the nursing needs for each patient upon admission, in that, 2 of 10 patients (Patient #5 on 1/3/18, and #6 on 2/7/18) medical record did not reflect a registered nurse assessed and evaluated the patient needs upon admission to the hospital prior to delegation of care to a Licensed Vocational Nurse (LVN).

Findings included

Patient #5's 1/3/18 medical record did not reflect a registered nurse (RN) assessed and evaluated the patient needs upon admission to the hospital prior to delegation of care to a Licensed Vocational Nurse (LVN). The first physical assessment was completed/signed by an LVN.

Patient #6's 2/7/18 medical record did not reflect a registered nurse (RN) assessed and evaluated the patient needs upon admission to the hospital prior to delegation of care to a Licensed Vocational Nurse (LVN). The first physical assessment was completed/singed by an LVN. The initial nursing assessment screening notifications were left blank/not completed by an RN.

During an interview on 2/13/18 ending at 4:32 PM, Personnel #1 and #2 were present to review the care plan findings above. Personnel #1 confirmed the above findings.

The January 2018, last revised "Nursing Assessment, Initial" policy required on page 2, "Admission Screening indicators...must be completed by the RN...the admission physical assessment must be performed by a Registered Nurse..."

Texas Board of Nursing - "15.28 The Registered Nurse Scope of Practice - Assessment: The comprehensive assessment is the first step, and lays the foundation for the nursing process. The comprehensive assessment is the initial and ongoing, extensive collection, analysis and interpretation of data. Nursing judgment is based on the assessment process. The RN uses clinical reasoning and knowledge, evidence-based outcomes, and research as the basis for decision-making and comprehensive care. Based upon the comprehensive assessment the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and a synthesis of knowledge. Surveillance is an essential step in the comprehensive assessment process. The RN must anticipate and recognize changes in patient conditions and determines when reassessments are needed."

Texas Board of Nursing - "15.27 The Licensed Vocational Nurse Scope of Practice - The LVN scope of practice is a directed scope of practice and requires appropriate supervision...There are limits to LVN scope of practice...The LVN cannot perform independent assessments as the LVN has a directed scope of practice under supervision...The RN ' s comprehensive assessment lays the foundation for the nursing process...This information (LVN) may be considered in planning, problem identification, nursing diagnoses, and formulation of goals, teaching plans and outcomes by the RN supervisor or another appropriate clinical supervisor. A nursing plan of care for patients is developed by the RN and thus the RN has the overall responsibility to coordinate nursing care for patients...Caution must be exercised not to overstep the legal parameters of nursing practice when an employer may not understand the limits of the LVN scope of practice."

Based on record review and interview, the facility failed to ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient which addresses the patient's needs, in that, 3 of 10 patients (Patient #6, #8, and #10) care plan was not kept current with appropriate plans of care, which addresses the patient's needs.

Findings included

Patient #6's (Diagnosis: end stage renal disease on dialysis) care plan did not include appropriate actions for a dialysis patient.

Patient #8's (Diagnosis: acute respiratory failure) care plan did not include appropriate actions for a respiratory patient.

Patient #10's (Diagnosis: tachycardia, acute respiratory failure, status post tracheostomy) care plan did not include appropriate actions for a respiratory or a cardiac patient.

During an interview on 2/13/18 ending at 1:28 PM, Personnel #2 was informed of the above findings of the care plans. Personnel #2 reviewed each and confirmed the findings.