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Based on record review and interview, the hospital failed to ensure a registered nurse (RN) supervised and evaluated the nursing care for each patient, in that, 4 of 4 (Patient #2, #3, #4, and #11) patient's records did not evidence a daily registered nurse assessment.

Findings Included

Patient #2's record did not evidence a registered nurse assessment for 4/09/16, 4/10/16, 4/14/16, and 4/15/16.

Patient #3's record did not evidence a registered nurse assessment for 5/04/16.

Patient #4's record did not evidence a registered nurse assessment for 12/13/15, 12/20/15, and 12/22/15.

Patient #11's record did not evidence a registered nurse assessment for 10/30/15, 11/01/15, 11/07/15, and 11/09/15.

During an interview on 5/18/16 at 1:48 PM, Personnel #2 was informed of the above findings for Patient #2, #3, and #4. Personnel #2 was asked to confirm the findings. Personnel #2 confirmed the findings and stated, "There is only an LVN (Licensed Vocational Nurse) assessment those days."

During an interview on 5/19/16 at 3:16 PM, Personnel #1 was informed of the above findings for Patient #11. Personnel #1 confirmed the findings and stated, "There is no RN assessment for those days."

The facility's 6/16/15 "Assessment and Reassessment - Nursing" policy required, "each patient is re-assessed by a Registered Nurse daily..."

Based on record review and interview, the hospital failed to keep current, a nursing care plan for each patient, in that, 6 of 6 (Patient #1, #2, #3, #7, #8, and #11) patient's care plans did not evidence updates to keep current the goals met or not met during the patient's stay.

Findings Included

Patient #1's, #2's, #3's, #7's, #8's, and #11's "Plan of Care" did not evidence updates to keep current the goals met or not met during the patient's stay.

During an interview on 5/19/16 at 3:20 PM, Personnel #2 was informed of the above findings. Personnel #2 was asked to verify the care plans had not been updated with patient goals met or not met by nursing. Personnel #2 verified the care plans had not been updated by nursing with patient goals met or not met during their stay. Personnel #2 said it was in the policy and she expected the nurses to update the patient goals as met or not met during their stay.

The facility's 6/16/15 "Plan of Care-Individualized and Interdisciplinary" policy required, "The individualized plan of care is developed based on initial assessment data from an interdisciplinary team, led by a physician and including, but not limited to a Registered Nurse...The plan is continuously evaluated and monitored for effectiveness in meeting its intended goals at team conferences, with updates or modifications a minimum of weekly or as necessary to monitor...Progress toward goals...Failure to make progress..."

Based on record review and interview, the facility failed to provide rehab services under the orders of a physician, in that, 12 of 12 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12) patient's records did not document a physician's order for their rehab (physical and occupational) therapy.

Findings Included

Patient #1's, #2's, #3's, #4's, #5's, #6's, #7's, #8's, #9's, #10's, #11's, and #12's record did not document a physician's order for their rehab (physical and occupational) therapy. Each patient had therapy documented during their hospital stay.

During an interview on 5/19/16 ending at 2:11 PM. Personnel #3 was informed of the above findings. Personnel #3 confirmed there were no physician's orders for rehab therapy and stated, "We look in the dictated History and Physical to see the dictated plan. It could also be in the progress note."

The facility's 6/16/15 "Plan of Care - Individualized and Interdisciplinary" required, "...appropriate to the patient's individualized assessed needs, strengths, limitations and goals...reviewed and revised based on the patient's response to treatment...type (Occupational, Physical, and Speech Therapy), amount, frequency and anticipated duration of services..."