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Based on record review and interview, the Hospital failed for one (Patient #1) patient out of a total sample of ten Out-patient records to ensure that nursing assessments were documented in the electronic medical record at the time the care was provided in order to develop ongoing plans of care for patients.
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Findings include

The Hospital policy titled, Nursing Patient Assessment policy, dated 6/28/18, indicated ongoing nursing reassessments should be completed and documented in the electronic medical record (EMR) on nursing flow sheets for infusion visits and every significant patient contact.

Patient #1's EMR, a flowsheet for intravenous line assessments dated 6/7/19 at 7:46 A.M., indicated that Patient #1's double lumen port was accessed.

Patient #1's EMR, dated 6/7/19 at 8:40 A.M., indicated that Nurse #1 was notified that Alteplase (anti-clotting medication) was administered because there was no blood return from the intravenous ports.

Patient #1's medication administration records, dated 4/7/19 at 11:30 A.M., indicated that intravenous (IV) medication was administered by Nurse #1; however, the nursing flow sheets indicated no further care provided or assessments regarding Patient #1's port and central catheter care before IV medications were administered.

A Nursing Progress Note regarding Patient #1's Out-patient clinic visit for 4/7/19 was documented on 4/10/19, three days after the clinic visit.

The Surveyor interviewed the Associate Chief Nursing Officer for the Out-Patient Clinics at 10:30 A.M. on 8/5/19. The Associate Chief Nursing Officer said it's a standard of nursing practice to document care at the time of the encounter or before the nursing shift ends either in a note or on the flowsheets.