HospitalInspections.org

Based on medical record review and interview with staff, the facility failed to ensure Daily Nursing Notes- patient assessments were complete and consistent with hospital policy and procedure.
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Findings included:
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Facility document titled, "Facility document titled, "Patient Assessment, Reassessment and High Risk Screens" states in part, "Purpose: to ensure that all patients receive the appropriate screening, assessment and reassessment by qualified individuals within the organization.
C. Reassessment
1. Each patient is reassessed according to the guidelines established by the clinical discipline. Multidisciplinary reassessment occurs during daily care of the patient and during interdisciplinary Team Meetings.
2. Reassessment is ongoing and may be triggered by key decision points and at any interval (s) specified by the department's ancillary directly involved in providing patient treatment and/or care.
3. Reassessment may be specified at regular intervals but determined by
a. The patient's treatment plan
b. The patient's response to treatment
c. Significant change in the patient's condition
d. Significant change in the patient's diagnosis
e. Discharge planning where appropriate, within the scope of care of the department involved.
f. Educational reassessment as appropriate during care conference or during the care of the patient.
4. Reassessment by each clinical discipline will be documented in the medical record.

In a review of Patient #1 medical record "Daily Nursing Notes" revealed incomplete nursing assessments. The "Skin Assessment" section was not completed on the following dates: 8/25/19, 8/27, 8/28, 8/29, 8/30, 8/31, 9/1, 9/2, 9/4, 9/5, 9/7, 9/8/19.
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The above findings were confirmed by Staff #1 on the afternoon of 9/16/19.