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Based on policy and procedure review, clinical record review and interview, it was determined the facility failed to obtain consent for treatment for three (#1, #4 and #8) of 13 (#1-5, #7-11, and #13-15) patients. Failure to obtain consent for treatment did not ensure the facility had the permission of the patient or their family to perform routine services such as venipunctures, X-rays and other customary care provided to hospitalized patients. The failed practice affected Patients #1, #4 and #8. Findings follow:

A. Review of the policy and procedure titled "Consent for Treatment," received on 08/27/18 showed the Conditions of Admission and Consent form was to be signed for each patient prior to sending them to a nursing unit. The form was to provide a record of the patient's consent to routine hospital care patients could receive while in the hospital.

B. Review of the clinical record of Patient #1 showed an admission date of 08/21/18. Review of the clinical record on 08/28/18 showed the Consent for Treatment was not signed. During an interview with the CNO (Chief Nursing Officer) at 1:15 PM on 08/28/18 the above findings were verified.

C. Review of the clinical record of Patient #4 showed an admission date of 08/24/18. Review of the clinical record on 08/28/18 showed the Consent for Treatment was not signed. During an interview with the CNO at 8:30 AM on 08/29/18 the above findings were verified.

D. Review of the clinical record of Patient #8 showed an admission date of 08/22/18. Review of the clinical record on 08/28/18 showed the Consent for Treatment was not signed. During an interview with the CNO at 8:30 AM on 08/29/18 the above findings were verified.

Based on clinical record review and interview, it was determined a Registered Nurse failed to assess and manage the patient's care, needs and response to treatment ordered by the physician for three (#1, #2 and #7) of fifteen (#1-15) clinical records reviewed in that there was no documentation tube feeding residuals were checked as ordered and neurological checks were performed every four hours as ordered. Failure to check residuals as ordered did not give the physician the necessary information needed to make clinical decisions regarding tube feeding rates and amounts, and did not ensure the nursing staff were holding the tube feedings as ordered. Failure to perform neurological checks every four hours as ordered did not ensure any decline in neurological status was detected and did not provide the responsible physician the necessary information to make informed decisions regarding the care and treatment of the patient. The failed practice had the potential to affect Patients #1, #2 and #7. Findings follow:

A. Review of Patient #1's clinical record showed physician's orders, dated and timed 08/21/18 at 4:41 PM, to check the tube feeding residuals every four hours and the first occurrence was to be at 8:00 PM on 08/21/18. Review of the clinical record showed the residuals were not documented until 8:00 PM on 08/22/18. There was no documentation of residual checks from 4:00 PM on 08/24/18 through 8:00 AM on 08/25/18, from 4:00 PM 08/26/18 through 8:00 AM on 08/27/18 and from 4:00 PM on 08/27/18 through 8:00 AM on 08/28/18. During an interview with the Quality Manager at 1:00 PM on 08/28/18 the above findings were verified.

B. Review of Patient #2's clinical record showed physician's orders, dated and timed 08/24/18 at 9:21 PM, to check the tube feeding residuals every six hours and the first occurrence was to be at midnight on 08/24/18. Review of the clinical record showed the residuals were not documented until 6:00 PM on 08/25/18. There was no documentation of residual checks from 5:58 PM on 08/26/18 through 3:11 AM on 08/27/18, no documentation from 3:11 AM to noon on 08/27/18 and no documentation at 6:00 PM on 08/28/18. During an interview with the Quality Manager at 11:00 AM on 08/28/18 the above findings were verified.

C. Review of Patient #7's clinical record showed physician's orders, dated and timed 8/24/18 at 3:42 PM, to check the tube feeding residuals every six hours and hold the feeding if the residual was greater than 300 mills (milliliters). Review of the clinical record showed the residuals were not documented from 11:00 PM on 08/25/18 through 11:16 AM on 08/26/18, and from 9:00 PM on 08/27/18 through 5:34 AM on 08/28/18.

D. Review of Patient #7's clinical record showed physician's orders, dated and timed 08/24/18 at 4:00 PM for neurological checks every four hours. Review of the clinical record showed no documentation of neurological checks from 7:00 AM to 7:00 PM on 08/25/18 and from 12:00 PM to 7:00 PM on 08/27/18. During an interview with the Quality Manager at 2:50 PM on 08/28/18 the findings in C and D were verified.