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Based on clinical record review and interview, it was determined the Facility failed to ensure patient assessments were done on each shift by a Registered Nurse (RN) for 17 (#3-#8 and #9-#20) of 20 (#1-#20) Patients. The failed practice did not ensure a Registered Nurse was aware of, and kept up to date on each patient's condition and current treatments. This failed practice had the likelihood of affecting all patients admitted to the Facility. Findings follow.

A. Review of clinical records revealed the following:
1) Patient #3 - admitted 02/25/16 - 03/16/16; 8 assessments not performed by an RN
2) Patient #4 - admitted 02/29/16 - 03/25/16; 17 assessments not performed by an RN
3) Patient #5 - admitted 05/16/16; 7 assessments not performed by an RN
4) Patient #6 - admitted 05/04/16; 17 assessments not performed by an RN
5) Patient #7 - admitted 05/20/16; 1 assessment not performed by an RN
6) Patient #8 - admitted 05/09/16; 15 assessments not performed by an RN
7) Patient #10 - admitted 05/03/16; 8 assessments not performed by an RN
8) Patient #11 - admitted 05/25/16; 4 assessments not performed by an RN
9) Patient #12 - admitted 05/23/16; 1 assessment not performed by an RN
10) Patient #13 - admitted 05/11/16; 4 assessments not performed by an RN
11) Patient #14 - admitted 05/03/16; 11 assessments not performed by an RN
12) Patient #15 - admitted 05/04/16; 4 assessments not performed by an RN
13) Patient #16 - admitted 05/10/16; 4 assessments not performed by an RN
14) Patient #17 - admitted 05/04/16; 5 assessments not performed by an RN
15) Patient #18 - admitted 05/09/16; 3 assessments not performed by an RN
16) Patient #19 - admitted 05/21/16; 3 assessments not performed by an RN
17) Patient #20 - admitted 05/16/16; 3 assessments not performed by an RN

B. During an interview on 05/27/16 at 1330, the Quality Director confirmed the assessments were not performed by an RN.