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Based on interview, medical record review and hospital document review, it was determined that facility staff failed to a) ensure that a registered nurse evaluated and assessed a patient's needs on admission for 1 of 9 patients included in the survey sample (Patient #6), and b) ensure that a registered nurse was actively supervising and evaluating the care delivered to patients by licensed practical nurses for 5 of 9 patients included in the survey sample. Patients' #5, 6, 7, 8 and 9.

The findings include:

On 10/26/16 during review of scheduled nursing coverage the surveyor was unable to determine by looking at the schedule whether a nurse was a registered nurse (RN) or a licensed practical nurse (LPN). The schedule contained headings for "nurses" and "C.N.A" (certified nursing assistants). Both nurses and C.N.A's work 12 hour shifts that are 7 am to 7 pm for day shift and 7 pm to 7 am for night shift. After being provided with a nursing personnel roster with titles, to compare with the assignment schedule, it was determined there were patients who were assigned to the care of an LPN and received assessments only by that LPN during a work shift.

Medical records were reviewed on 10/27/16 with the assistance of a navigator (Employee #14). Surveyor review of medical record for Patient #5 revealed on 10/19/16 nursing care and patient assessments were completed by an LPN for both day and night shifts. On 10/20/16 nursing care and patient assessments were completed by an LPN on day shift. The medical record failed to provide evidence of RN supervision or evaluation of the care provided by the LPN's on those dates.

Review of the medical record for Patient #6 revealed an admission assessment date of 9/22/16 by an RN which began at 4 pm but failed to provide evidence of a time of completion. The medical record further revealed on 10/19/16, Patient #6 received nursing care and patient assessment by an LPN on day shift and no further assessment for that date. The medical record failed to provide evidence of RN supervision or evaluation of the care provided by the LPN on that date.

Review of the medical record for Patient #7 revealed for the dates 10/19/16 and 10/20/16, the patient received nursing care and assessment by an LPN for two of four shifts and on 10/24/16 and 10/25/16 nursing care and assessments were completed by an LPN. The medical record failed to provide evidence of RN supervision or evaluation of the care provided by the LPN on those dates.

Review of the medical record for Patient #8 revealed on 9/13/16 nursing care and patient assessments were completed by an LPN on night shift. The medical record failed to provide evidence of RN supervision or evaluation of the care provided by the LPN on that date.

Review of the medical record for Patient #9 revealed on 9/14/16 the patient had an assessment initiated by an RN on day shift but failed to provide evidence the assessment was completed. The medical record further revealed an assessment on night shift 9/14/16 by an LPN. The medical record failed to provide evidence of RN supervision or evaluation of the care provided by the LPN on that date.

On 10/27/16 in an interview with Employee #15 (an RN), the surveyor asked if he/she had ever been asked to review or validate the findings of an LPN. Employee #15 stated that he/she had never been asked to sign or validate an LPN's assessment and that LPN's do their own assessments, with the exception of admission assessments which are always done by a RN. Employee #15 further stated that he/she had never been assigned to supervise the care an LPN provided and that if there were medications that an LPN could not give, the LPN usually just found an RN who had time to give the medication. When asked who supervised the LPN's, Employee #15 stated that he/she guessed the nursing supervisor would.

The morning of 10/27/16, the surveyor asked Employee # 16 a nursing supervisor where it would be documented in the medical record that an RN had "signed off" or approved an LPN's nursing assessment. Employee #16 stated that he/she did not know how or where that would find that in the record.

During medical record review Employee #14, who was acting as navigator for the surveyor, was asked if he/she had ever been asked to validate an LPN's assessment of a patient. He/she stated "I've never had to and would not know where to document that".

The surveyor reviewed the following hospital documents:

Hospital document "Job Description and Competencies Licensed Practical/Vocational Nurse-IV Certified' states in part, "The staff LPN/LVN shall ensure that the unit to which assigned shall function in a smooth, organized and efficient manner as directed by the Registered Nurse."

The hospital document "Plan for the Provision of Care" under the heading "Assignment of Patient Care" states in part "At the beginning of each shift, a registered nurse supervisor assigns patient care according to the needs of the patient along with the level of nursing care required and the qualifications and competence of available nursing staff. Assignment must reflect RN accountability for each patient."

The hospital document "Assessment and Reassessment" states in part "A patient's need for care related to his/her admission is assessed by a Registered Nurse. Patient needs, response to treatments/interventions, and change in condition or diagnosis are reassessed as necessary and at a minimum of every shift" and "An RN is responsible for completing a head to toe assessment at a minimum of once in a 24 hour period."

These findings were discussed with the management team on the afternoon of 10/27/16. The survey team explained the basis for the deficient practice and allowed time for questions. No further information was provided to the survey team.