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Based upon reviews of 7 of 9 medical records, policies and procedures, Administrative and staff interviews, the Registered Nurse (RN) failed to ensure each patient (#s 1,2,3,4,5,6 and 9) received a daily nursing assessment performed and documented by the RN as required by hospital policy. Findings:

Review of patient #1's medical record revealed admission diagnoses of diskitis with an abnormal lumbar MRI (Magnetic Resonance Imaging) and anemia. The admission date was 06/03/10. Review of the daily nursing assessment forms revealed: June 04 through the 15th and June 17th through the 23rd, there lacked a documented assessment by an RN. Patient #1 was discharged on June 23, 2010.

Review of patient #2's medical record revealed an admission date of 12/09/10. Review of Intake and Output forms revealed on 12/10/10 and 12/11/10 there lacked documentation relative to a bowel movement. Review of the daily nursing assessments (12/11/10), revealed S18LPN documented under the section titled "Gastrointestinal" that his abdomen was "firm" and bowel sounds were "hypoactive" on the 7a-7p shift; S20LPN documented his abdomen as "firm" but left the bowel sounds portion blank. Review of daily nursing assessment forms, dated 12/09/10 through 12/16/10, revealed patient #2 had not received a documented assessment by an RN since the initial nursing assessment conducted on 12/09/10.

Review of patient #3's medical record revealed an admission date of 12/08/10. Review of the daily nursing assessments revealed, after the initial nursing assessment documented by S25 RN, there lacked a documented assessment by an RN from 12/08/10 through 12/16/10.

Review of patient #4's medical record revealed a 95 year old male with diagnoses of Peripheral Vascular Disease (PVD), s/p (status post) AKA (above knee amputation), Febrile illness, Protein malnutrition, Renal insufficiency who presents with severe PVD and Right foot gangrene. Admission date was 02/25/10 and he was discharged 03/31/10. Review of the Daily Nursing Assessment forms revealed there failed to be a documented assessment by an RN from 02/26/10 through 03/31/10.

Review of patient #5's medical record revealed a form titled "Daily Nursing Assessment", dated 05/09/10. Continued review revealed S13 Licensed Practical Nurse (LPN) documented, "1758 (5:58pm) Patient c (with) mouth twitching rapidly, head jerking from side to side, Eyes bucked and in a trance. Skin remain dry. Drooling from the mouth. 1800 (6pm) Dr. (name S23 physician) beeped. Pt. (patient) jerking last about a minute c seizure like activities. 1810 (6:10pm) Orders received for Ativan 1mg (milligram) IVP (intravenous push) now and Cerebyx 1GM (gram) IVPB (intravenous piggy back) over an hour." Continued review of the Daily Nursing Assessment, 05/09/10 revealed S13 LPN documented the above order medications were administered by the Registered Nurse (RN); however, there failed to be an assessment documented by an RN relative to the change in patient #5's condition. Further review of the Daily Nursing Assessment form, 05/09/10 revealed patient #5 had not received a documented and complete nursing physical assessment as per hospital policies (#s 201-21-025.5 and 201-31-002.3); nor had patient #5 received an update to her nursing care plan that reflected a change in her condition which required increased monitoring as a result of the seizure activity.

Continued review of the nursing care plan (04/13/10) revealed under the section "Bowel and Bladder Function" this entire section lacked documentation even though this was an area identified as a problem area for patient #5. There failed to be documented evidence the RN reassessed and provided continual monitoring of patient #5's bowel function.

Review of the nursing care plan, dated 04/13/10, revealed under the section for "Fluid/Electrolyte Status" there was an area titled "Basic Care to include: monitoring of mucous membranes and tugor; monitoring for edema;...monitoring input and output..." Continued review revealed this section lacked documentation of interventions utilized, nor was there any other documentation in this area.

Review of Intake and Output forms revealed the RN failed to identify patient #5 had a documented bowel movement for the following dates: 04/15/10, 04/19/10, 04/25/10, 04/27/10,04/28/10, 04/29/10, 05/01/10, 05/08/10, 05/09/10, 05/10/10, 05/14/10, 05/15/10, 05/18/10, 05/20/10, 06/06/10, 06/09/10, 06/18/10, 06/19/10; no documented bowel movement for the following 5 consecutive days: 06/23/10, 06/24/10, 06/25/10, 06/26/10, 06/27/10; 06/29/10, 06/30/10; no bowel movement for the following 5 consecutive days: 07/04/10, 07/05/10, 07/06/10, 07/07/10, and 07/08/10. The RN failed to ensure the nursing care plan was followed as implemented.

Review of the Daily Nursing Assessments for the above dates revealed patient #5 had not received a complete documented assessment under the section titled "Gastrointestinal"; nor was there an RN re-assessment conducted and documented to reflect a potential problem as a result of a lack of a documented bowel movement as noted on the above dates. Patient #5 lacked a documented RN assessment for the following dates: April 14th through the 30th; May 1st through the 9th, 17, 18, and 22nd through the 30th; June 2,3,6,7,8,11,12,13,16,17,21 and 23rd through the 30th; July 3,5,6,and 7th, patient #5 was discharged to a local Nursing Home on July 8, 2010.

Review of patient #6's medical record revealed a 92 year old female admitted, 04/29/10, with diagnoses of Sputum Positive for MRSA (Methicillin Resistant Staphylococcus aureus), Pneumonia, Atrial-fibrillation, High blood pressure, who complains of shortness of breath. Review of the Daily Nursing Assessments revealed, after the initial nursing assessment was completed (04/29/10) by the RN, patient #6's record failed to contain documentation that an RN had reassessed and documented an evaluation from 04/30/10 through 06/01/10. Patient #6 was discharged on 06/02/10.

Review of patient #9's medical record revealed a 77 year old female admitted, 12/08/10, with diagnoses of Respiratory Failure, Cellulitis, Chronic Kidney Disease, Hypertension, and Anemia. Continued review of the medical record revealed 2 Daily Nursing Assessment forms, dated 12/17/10 and 12/18/10; however, there failed to be an assessment documented by the RN for these 2 days.

Review of hospital policy # 201-21-025.5, titled "Nursing Assessment" revealed the purpose "to ensure a Registered Nurse assesses the patients' need for nursing care and plans, implements and evaluates that care." Review of a section titled "Procedure" revealed, "...The Registered Nurse will be responsible for performing the admission physical assessment and subsequent physical reassessment as warranted by the patient's condition...A complete physical reassessment will be conducted and documented every shift thereafter. In addition, reassessments will be conducted as warranted by the patient's condition...A registered nurse supervises and evaluates the nursing care for each patient."

Review of hospital policy #201-31-002.3, titled "Documentation-Charting" revealed, "...To provide a legal record of the patient's care and condition and to give members of the health team a means of communicating with each other, and documentation of information for continuity of care...Procedure A. Documentation should be pertinent and concise and should reflect the patient's status. B. Charting should address the patient's needs, problems, capabilities and limitations. C. Nursing interventions and patient responses are noted in the medical record. Documentation shows: 1. Patient response to medical orders. 2. Patient response to implementation of the nursing care plan...8. Make sure the charting reveals a continuing monitoring of the patient..."

Interviews, on 12/17/10 and 12/21/10, with S2 Director of Nursing and S3 LPN Director Quality/Risk Management revealed patients were to be re-assessed by an RN any time there was a change in the patients' condition or at least every 24 hours per hospital policy. S2 and S3 agreed patient #s 1,2,3,4,5,6 and 9 had not received RN assessments at least every 24 hours or when the patient experienced a change in their condition.

Based upon review of 2 of 9 medical records (#5, #9), policies and procedures and staff interviews the hospital failed to ensure the Registered Nurse (RN) updated/implemented the patient's nursing care plan when: 1) patient #5 experienced seizure activity and required placement on telemetry; 2) no bowel movements for multiple days (patient #5); and 3) a care plan with interventions relative to the administration of an anticoagulant (#9). Findings:

Review of the nursing care plan implemented for patient #5 revealed on 04/13/10 the Admitting Diagnoses were listed as Acute Renal Failure, Stage IV Decubitus Ulcer and the primary treatment(s) identified on admission were Wound Care and Treatment of Infection. Other significant problems identified were fluid/electrolyte status, infection, bowel/bladder function and skin integrity.

Review of a form titled "Daily Nursing Assessment", dated 05/09/10, revealed S13 Licensed Practical Nurse (LPN) documented, "1758 (5:58pm) Patient c (with) mouth twitching rapidly, head jerking from side to side, Eyes bucked and in a trance. Skin remain dry. Drooling from the mouth. 1800 (6pm) Dr. (name S23 physician) beeped. Pt. (patient) jerking last about a minute c seizure like activities. 1810 (6:10pm) Orders received for Ativan 1mg (milligram) IVP (intravenous push) now and Cerebyx 1GM (gram) IVPB (intravenous piggy back) over an hour." Continued review of the Daily Nursing Assessment, 05/09/10 revealed S13 LPN documented the above order medications were administered by the Registered Nurse (RN); however, there failed to be an assessment documented by an RN relative to the change in patient #5's condition. Further review of the Daily Nursing Assessment form, 05/09/10 revealed patient #5 had not received a documented and complete nursing physical assessment as per hospital policies (#s 201-21-025.5 and 201-31-002.3); nor had patient #5 received an update to her nursing care plan that reflected a change in her condition which required increased monitoring as a result of the seizure activity.

Continued review of the nursing care plan (dated 04/13/10) revealed under the section "Bowel and Bladder Function" this entire section lacked documentation even though this was an area identified as a problem area for patient #5.

Review of the nursing care plan, dated 04/13/10, revealed under the section for "Fluid/Electrolyte Status" there was an area titled "Basic Care to include: monitoring of mucous membranes and tugor; monitoring for edema;...monitoring input and output..." Continued review revealed this section lacked documentation of interventions utilized, nor was there any other documentation in this area.

Review of Intake and Output forms and daily nursing notes revealed the RN failed to identify and implement a nursing care plan when patient #5 lacked a documented bowel movement for the following dates: 04/15/10, 04/19/10, 04/25/10, 04/27/10,04/28/10, 04/29/10, 05/01/10, 05/08/10, 05/09/10, 05/10/10, 05/14/10, 05/15/10, 05/18/10, 05/20/10, 06/06/10, 06/09/10, 06/18/10, 06/19/10; no documented bowel movement for the following 5 days: 06/23/10, 06/24/10, 06/25/10, 06/26/10, 06/27/10; 06/29/10, 06/30/10; no bowel movement for the following 5days: 07/04/10, 07/05/10, 07/06/10, 07/07/10, and 07/08/10.

Review of the Daily Nursing Assessments for the above dates revealed patient #5 had not received a complete documented assessment under the section titled "Gastrointestinal"; nor was the nursing care plan updated to reflect a potential problem as a result of a lack of a documented bowel movement as noted on the above dates.

Review of patient #9's medical record revealed a 77 year old female admitted, 12/08/10, with diagnoses of Respiratory Failure, Cellulitis, Chronic Kidney Disease, Hypertension, and Anemia. Review of the Initial Nursing Assessment/Care Plan, dated 12/08/10, revealed patient #9 had "Anticoagulation Therapy" identified as a problem; however continued review of the nursing care plan failed to indicate patient #9 had any interventions or evaluations relative to the anticoagulation therapy, (i.e. monitoring for bruising, bleeding gums).

Review of hospital policy # 201-21-025.5, titled "Nursing Assessment" revealed the purpose "to ensure a Registered Nurse assesses the patients' need for nursing care and plans, implements and evaluates that care." Review of a section titled "Procedure" revealed, "...The Registered Nurse will be responsible for performing the admission physical assessment and subsequent physical reassessment as warranted by the patient's condition...A complete physical reassessment will be conducted and documented every shift thereafter. In addition, reassessments will be conducted as warranted by the patient's condition...A registered nurse supervises and evaluates the nursing care for each patient."

Review of hospital policy #201-31-002.3, titled "Documentation-Charting" revealed, "...To provide a legal record of the patient's care and condition and to give members of the health team a means of communicating with each other, and documentation of information for continuity of care...Procedure A. Documentation should be pertinent and concise and should reflect the patient's status. B. Charting should address the patient's needs, problems, capabilities and limitations. C. Nursing interventions and patient responses are noted in the medical record. Documentation shows: 1. Patient response to medical orders. 2. Patient response to implementation of the nursing care plan...8. Make sure the charting reveals a continuing monitoring of the patient..."

The RN failed to follow hospital policy and procedures relative to implementation of the plan of care for patient #5. During the initial admission assessment, S24 RN identified on the plan of care the patient had the potential for alteration in bowel/bladder function; however, there failed to be documented evidence the RN re-assessed the patient's abdomen and daily bowel movements and implemented nursing interventions to ensure the patient was monitored for bowel movements.

The RN failed to follow hospital policies and procedures relative to implementation of a nursing plan of care for patient #9. During the initial admission assessment, the RN identified on the plan of care that patient #9 was to receive anticoagulation therapy; however there failed to be documented evidence the RN implemented nursing interventions to ensure the patient was monitored for potential problems associated with anticoagulation therapy, (such as bruising, bleeding gums).

Interviews, 12/21/10, with S2 Director of Nursing and S4 RN Manager confirmed Nursing Care Plans were to be updated any time there was a change in the patients' condition. S2 and S4 agreed the Nursing Care Plan had not been updated for patient #5 to reflect the change in her condition as a result of new seizure activity (documented on 05/09/10), and to monitor and evaluate patient #5's daily bowel movements; nor was patient #9's nursing care plan implemented to monitor the patient for potential problems associated with anticoagulation therapy.

Based upon reviews of 7 of 9 medical records (#s1,2,3,4,5,6,9), policies and procedures, Quality Assurance/Performance Improvement (QA/PI) indicators/data, Administrative and staff interviews, the hospital failed to ensure quality indicators were developed to track and analyze processess of care as evidenced by 1) the failure of the Registered Nurse (RN) to perform and document (per hospital policies) an assessment on each patient at least every 24 hours (#s 1,2,3,4,5,6,9) and when the patients' condition warranted a re-assessment (#5); and 2) updated and implemented nursing interventions by use of a nursing care plan when the patient has had a change in their condition as evidenced by new onset of seizure activity and a lack of bowel movements for 5 days (#5). Findings:

Review of the Daily Nursing Assessment forms for patient #s 1, 2, 3, 4, 5, 6, and 9 revealed none had received a documented RN assessment at least every 24 hours per policies.

Interview, on 12/20/10, with S2 Director of Nursing (DON) revealed the RN Charge Nurse was responsible for documenting the supervision of patient care performed by Licensed Practical Nurses (LPN). After S2 DON examined the medical records (#1,2,3,4,5,6,9) he agreed the patients had not received a documented RN assessment every 24 hours; nor
had patient #5 received an RN assessment 1) when she experienced seizure activity and required the administration of Levophed intravenously (IV) to maintain her blood pressure; and 2) when patient #5 had experienced a lack of bowel movements for 5 days, which had occurred on two different occasions.

Review of hospital policy # 201-21-025.5, titled "Nursing Assessment" revealed the purpose "to ensure a Registered Nurse assesses the patients' need for nursing care and plans, implements and evaluates that care." Review of a section titled "Procedure" revealed, "...The Registered Nurse will be responsible for performing the admission physical assessment and subsequent physical reassessment as warranted by the patient's condition...A complete physical reassessment will be conducted and documented every shift thereafter. In addition, reassessments will be conducted as warranted by the patient's condition...A registered nurse supervises and evaluates the nursing care for each patient."

Review of hospital policy #201-31-002.3, titled "Documentation-Charting" revealed, "...To provide a legal record of the patient's care and condition and to give members of the health team a means of communicating with each other, and documentation of information for continuity of care...Procedure A. Documentation should be pertinent and concise and should reflect the patient's status. B. Charting should address the patient's needs, problems, capabilities and limitations. C. Nursing interventions and patient responses are noted in the medical record. Documentation shows: 1. Patient response to medical orders. 2. Patient response to implementation of the nursing care plan...8. Make sure the charting reveals a continuing monitoring of the patient..."

Review of the QA/PI indicators revealed the indicators developed for nursing were pain assessments, completion of the initial nursing assessments, First dose medications, Fall assessments, and critical laboratory values.

Interview, on 12/21/10, with S3 LPN Quality/Risk Manager revealed the above nursing indicators were developed in August 2010 and would be monitored for at least 6 months (Feb. 2011) to ensure compliance by nursing personnel. S3 stated once determined, in February 2011, that nursing personnel are not meeting the threshold of 90%, the indicators would be continued. S3 was questioned about the lack of documented RN assessments on patients at least every 24 hours (#s 1,2,3,4,5,6,9) and the re-assessment of patient #5 when she experienced seizures and the need of a re-assessment when patient #5 did not experience a bowel movement for 5 days (this occurred twice, once no bowel movement for 5 days-06/23/10 through 06/27/10 and again on 07/04/10 through 07/08/10). S3 stated in the past (2009) they had monitored RN assessments and had met the threshold that had been set; as a result of meeting the threshold different nursing indicators were selected (Fall assessments, pain assessments).

Interview, on 12/21/10, with S2 DON and S3 QA/Risk manager confirmed they were not aware the RN had not been supervising and documenting assessments on patients.