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A. Based on review of documents and interview with staff, it was determined the facility failed to ensure the Registered Nurse (RN) adequately documented assessments of patients and the supervision of care provided to at least three (3) of ten (10) patients reviewed. The hospital failed to ensure a Registerd Nurse (RN) documented a complete assessment on each patient at least every twenty-four (24) hours in accordance with hospital policy for patients #1, 3 and 8. This has the potential to adversely affect the quality of nursing care provided to all patients. Findings include:

1. Review of hospital policy "Daily Nursing Documentation/Physical Assessment", last revised 9/09, revealed the policy states "The nursing reassessment is to be completed by the RN once every 24 hours."

2. The medical record for patient #1 revealed the patient was assessed by the RN on 12/21/09 at 14:00. The next assessment by an RN was on 12/22/09 at 20:30, which was an interval longer than twenty-four (24) hours. Also, only Licensed Practical Nurses (LPN) made entries in the medical record during that interval.

3. The medical record for patient #3 revealed the patient was assessed by the RN on 1/7/10 at 16:30. An "assessment" form was placed on the medical record and dated 1/8/10, but the form was blank and had no entries by any nurse. The next assessment document by an RN was on 1/10/10 at 20:00. There was one entry by an RN during the interval between assessments, but the entry was not a complete assessment.

4. The medical record for patient #8 revealed the RN documented an assessment on 1/1/10 at 09:35. The next documented RN assessment was on 1/2/10 at 23:00. There were no RN notes between the two assessments, which was at an interval longer than twenty-four (24) hours.

5. The records were reviewed with the Quality Assessment/Performance Improvement (QAPI) Director and with the Vice President (VP) of Nursing in the morning on 3/24/10. They concurred with the findings in the records.


B. Based on review of documents and interview with staff, it was determined the facility failed to ensure the Registered Nurse (RN) adequately documented assessments of patients and the supervision of care provided to at least one (1) of ten (10) patients reviewed (patient #1). The hospital failed to ensure a RN documented follow-up intervention and/or assessment when a LPN documented variances in patient care or condition. This has the potential to adversely affect the quality of nursing care provided to all patients. Findings include:

1. Review of the medical record for patient #1 revealed that on the first evening of admission on 12/21/09, the LPN documented at 19:30 the patient complained of a severe headache and the patient rated the pain 8/10. The patient received a Lortab at that time. At 21:00, the LPN documented the patient's pulse was elevated at 142 peripheral and 120-130 apical. The LPN documented that the charge nurse was informed. On 12/22/09 at 01:00, the LPN documented the patient's pulse remained elevated at 120 and the charge nurse was informed. The LPN documented about the elevated pulse again at 02:30. At 04:15, the LPN documented the pulse was 107 and that the charge nurse was informed. At 08:45, the LPN documented the patient's blood pressure was low at 106/71 and that the blood pressure medication was not given. There was never any RN note during the time the LPN was documenting the variances in the patient's condition. The next RN note was the assessment documented on 12/22/09 at 23:30.

2. Also for patient #1, on 12/27/09 the LPN documented a small amount of drainage from the patient's surgical wound, which was a change in the patient's condition. There had never been any drainage noted from the wound until that time. The LPN documented the charge nurse was informed. There was no entry by the RN to indicate the RN assessed the patient at that time relative to the drainage. The next RN assessment was on 12/28 at 08:30 when the RN wrote "C/D/I" (clean, dry, intact) in the wound assessment space on the assessment form.

3. The record was reviewed with the Quality Assessment/Performance Improvement (QAPI) Director and with the Vice President (VP) of Nursing in the morning on 3/24/10. They concurred with the findings in the records.


C. Based on review of documents and interview with staff, it was determined the facility failed to ensure the Registered Nurse (RN) adequately documented assessments of patients and the supervision of care provided to at least one (1) of ten (10) patients reviewed. The hospital failed to ensure the RN documented an assessment of wounds at least every twenty-four (24) hours in accordance with policy. This has the potential to adversely affect the quality of nursing care provided to all patients. Findings include:

1. Review of hospital policy "Daily Nursing Documentation/Physical Assessment", last revised 9/09, revealed the policy states "The nursing reassessment is to be completed by the RN once every 24 hours."

2. Review of the medical record for patient #1 revealed that on the daily assessment form completed by a RN, there is a block "Surgical Incision/Wound" that is to be completed during the assessment. The block has two lines "location" and "description" to be filled in by the RN. On the assessment form completed on 12/23/09, the RN wrote "left scalp 2 incision to". The entry had not been completed with a description of the wounds.

On 12/24/09, the RN documented "left scalp, 2 incisions." The entry did not include a description of the wound.

On 12/25/09, the RN documented "left scalp, 2 incisions, open to air." The entry did not include a description of the wounds.

On 12/27/09 at 07:55, the RN documented "left scalp, incisions open to air." The entry did not include a description of the wounds.

3. The record was reviewed with the QAPI (Quality Assessment/Performance Improvement) Director and with the VP (Vice President) of Nursing in the morning on 3/24/10. They concurred with the findings in the record.