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Based on document review and interview, the facility failed to follow its policy/procedures and ensure periodic safety checks were documented for 1 of 10 medical records (MR) reviewed (Patient #9).

Findings include:

1. Review of the policy/procedure K.11.07 Restraints and Seclusion (reviewed 5-21) indicated the following: "Patient Monitoring: Patients in restraint will be monitored by trained staff as follows: Every two (2) hours... Document on Restraint Management Documentation Form."

2. Review of the policy/procedure O.15.10 Medical Record Contents (reviewed 12-20) indicated the following: "The clinical observations upon which care is based are a critical part of the medical record."

3. Review of the MR for Patient #9 indicated on the morning of 5-15-21 the patient experienced acute on chronic respiratory failure requiring intubation and mechanical ventilation and indicated bilateral soft wrist restraints were ordered on 5-15-21 at 0830 hours to prevent self-injury. The MR indicated soft wrist restraints were reordered on 5-16-21 at 0705 hours and on 5-17-21 at 0705 hours and lacked documentation of periodic restraint safety checks using the Restraint Management Documentation Form AMG-NN-002 for the indicated dates.

4. On 6-30-21 at 1740 hours, the Chief Clinical Officer A2 confirmed the above.

Based upon document review and interview, the facility failed to ensure a Registered Nurse documented a patient's change in condition and supervised and evaluated the care provided to each patient for 3 of 10 medical records (MR) reviewed (Patient's #1, 5 & 8)

Findings include:

1. Review of the policy/procedure I.9.00 Assessment and Reassessment (reviewed 1-21) indicated the following: "A RN will perform and document the initial admission assessment and thereafter a head to toe assessment in every 24 hour period... The LPN/LVN must notify the RN of abnormal findings and deterioration in the patient's condition for assessment, physician notification (if applicable), and evaluation of interventions... Any deteriorating change in the patient's condition shall require an immediate reassessment and documentation by a Registered Nurse."

2. Review of the policy/procedure I.9.02 Plan of Care (reviewed 1-21) indicated the following: "A Registered Nurse (RN) plans the nursing care of each patient that he/she is responsible for... Patients are evaluated on a regular basis as delegated by the Registered Nurse."

3. Review of the MR entry for Patient #1 on 6-21-21 at 0430 hours by the Licensed Practical Nurse (LPN) N11 indicated the following: "... Patient had no breath sounds. Patient was deceased..." and no documentation by a Registered Nurse was identified.

4. On 6-29-21 at 1240 hours, the Director of Quality Management A6 confirmed the MR for Patient #1 lacked the above.

5. Review of the MR for Patient #5 lacked documentation indicating a Registered Nurse completed a head to toe assessment on 6-1-21 from 0700 hours until 6-2-21 at 0700 hours.

6. On 6-30-21 at 1510 hours, staff A6 confirmed the MR for Patient #5 lacked the above.

7. Review of the MR for Patient #8 lacked documentation indicating a Registered Nurse completed a head to toe assessment on 6-25-21 from 0700 hours until 6-26-21 at 0700 hours.

8. On 6-30-21 at 1650 hours, the Chief Clinical Officer A2 confirmed the MR for Patient #8 lacked the above.

Based upon document review and interview, the facility failed to ensure a Registered Nurse assigned the care of each patient in accordance with the patient's needs for 3 of 14 days sampled for review (6-15-21, 6-20-21 & 6-25-21).

Findings include:

1. Review of the policy/procedure I9.02 Plan of Care (reviewed 1-21) indicated the following: "Patients are evaluated on a regular basis as delegated by the Registered Nurse."

2. Review of the policy/procedure D4.01 Staffing Plan (reviewed 9-19) indicated the following: "The RN maintains responsibility for coordinating the plan of care for each patient."

3. Review of administrative documentation titled Staffing Sheet for the period from 6-13-21 through 6-26-21 failed to indicate the night shift patient assignments on 6-15-21, 6-20-21 and 6-25-21 for each nursing staff listed as on duty for the indicated dates.

4. On 6-30-21 at 1230 hours, the Chief Clinical Officer A2 confirmed the above.

Based upon document review and interview, the Chief Clinical Officer failed to ensure that all nursing staff followed the facility's policy/procedures and initiated emergency resuscitative measures for 1 of 10 medical records (MR) reviewed (Patient #1).

Findings include:

1. Review of the policy/procedure K.11.04 Rapid Response - Code Blue (revised 1-20) indicated the following: "If the patient develops cardiac and/or respiratory arrest, the nurse caring for the patient as well as the Rapid Response Team members will initiate the "Code Blue ...Initiate BLS [Basic life support] and initiate ACLS [Advanced cardiac life support] protocol per current AHA [American Heart Association] guidelines."

2. Review of the MR for Patient #1 indicated admission orders on 6-19-21 at 1400 hours including an order for Full Code.

3. Review of the MR entry on 6-21-21 at 0430 hours by the Licensed Practical Nurse N11 indicated the following: "I went into the patient's room to administer morning medications, patient had no breath sounds. Patient was deceased, 2 nurses verified that there were no breath or heart sounds. MD notified ..." and no documentation indicated nursing staff attempted resuscitative measures without return of spontaneous circulation.

4. On 6-29-21 at 1240 hours, the Director of Quality Management A6 confirmed the MR for Patient #1 indicated an order for Full Code and no MR documentation on 6-21-21 indicated resuscitative measures were attempted by nursing staff when the patient was observed without signs of life.