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Based on interview and record review, the facility failed to ensure patient safety as evidenced by the RN ' s neglect to notify the physician of changes in the mental and physical condition of 1 (Patient #1) of 1 patients.

Findings included:

TX00236484

Record review of Progress Notes by RN #64 for Sunday, 01/17/2016, revealed:
(1) At 0911 the patient was " sitting up in chair by nurse ' s station, confused, yells out at times and continues to be lethargic, consistent drooling noted, vital signs stable. All morning medications held at this time. "
(2) At 0950 " breakfast not given due to patient constantly drooling. Unable to swallow his saliva when asked. "

Record review of the Nursing Physical Assessments revealed:
(1) On 01/14/2016 at 1120 RN #65 documented, " Swallowing Ability Normal. "
(2) On 01/15/2016 at 0900 RN #66 documented, " Swallowing Ability Normal. "
(3) On 01/16/2016 at 0900 Licensed Vocational Nurse (LVN) #62 documented, " Swallowing Ability Abnormal. "
(4) On 01/17/2016 at 0900 RN #64 documented, " Swallowing Ability Abnormal. "

Record review of the Medication Administration Record dated 01/17/2016 at 0900 by RN #64 revealed: Clonazepam 1mg HELD.

In an interview with RN #64 on 05/05/2016 at 1130, she stated:
(1) She was the charge nurse on Sunday, January 17, 2016.
(2) She normally worked at the other facility location and did not know the patients.
(3) She told the Clinical Nursing Assistant (CNA) to " hold off on feeding " Patient #1 because of the excessive drooling.
(4) She held the morning medications due to sedation.
(5) Patient #1 ' s wife was upset over her husband ' s care and condition. RN #64 paged MD #55.

In an interview with Medical Doctor (MD) #55 on 05/05/2016 at 0900, he stated that RN #64 did not report to him Patient #1 ' s change in mental condition and difficulty swallowing or the withholding of medications. " A nurse can make a judgment to hold a medication but needs to notify me within an hour or two. " He also stated he believed Patient #1 ' s confusion was related to the urinary infection and had he known of the patient ' s condition, he would have checked labs, started another antibiotic, decreased meds causing sedation and started intravenous fluids.

In an interview with Physician Assistant (PA) #54 (who works with MD #55) on 05/05/2016 at 0915, she stated, " I would like to have been notified of the changes - drooling and decreased swallowing ... I would have changed the Bactrim to another medication ... I would have held the Klonopin. " She also stated she needs to be notified when medications are held.

In an interview with MD #61 on 05/05/2016 at 1010, he stated he wants to know of medically significant changes with his patients. He also stated that he is to be notified of medications being held.

Record review of the Facility's Policy and Procedure "Family Notification of Changes in Patient Condition" dated January 2008 revealed: " In the event of a mental or physical change in a patient ' s condition due to illness, accident or injury, the attending physician, the Administrator-On-Call and the family shall be notified ... When a nurse judges a change in patient condition, he/she should attempt to notify the Physician Assistant or the attending physician. If the attending physician cannot be reached, the nurse should notify the Medical Director or designee. "

Based on interview and record review, the facility failed to ensure that the Registered Nurse (RN) provided supervision of nursing care as evidenced by 5 (Patient #3, #6, #8, #14 and Patient #15) of 12 (Patient #1, #3, #5, #6, #7, #8, #9, #10, #13, #14, #15, and Patient #16) patients did not have a Nursing Assessment by an RN during every 24-hour period. The policy and procedure clearly stated that the RN was to perform an assessment every 24 hours.

Findings included:

TX00236484

Record review of twelve medical records (Patient #1, #3, #5, #6, #7, #8, #9, #10, #13, #14, #15, and Patient #16) revealed:

On 01/16/2016 Licensed Vocational Nurse (LVN) #62 performed the 0700-1900 Daily Nursing Assessment and LVN #63 performed the 1900-0700 Daily Nursing Assessment on Patient #1, #6, #14, and Patient #15. There was no Daily Nursing Assessment completed by an RN during this 24 hour period.

On 04/30/2016 LVN #59 performed the 0700-1900 Daily Nursing Assessment and LVN #70 performed the 1900-0700 Daily Nursing Assessment on Patient #8. There was no Daily Nursing Assessment completed by an RN during this 24 hour period.

In an interview with Quality Director #51 on 05/05/2016 at 1400, she stated the RN is to perform and document one of the two 12-hour nursing assessments and that an LVN could perform the other 12-hour assessment under the supervision of the RN. She also stated she was not aware that there were instances in which the LVN was performing both 12-hour nursing assessments within a 24-hour period.

Record review of the Facility ' s Policy and Procedure "Plan for the Delivery of Patient Care" dated April 2016 revealed; " IV. Professional Patient Care Staff: Roles and Functions ... RN assessment every 24 hours. "