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Based upon document review and interview, the nurse executive failed to ensure that the policy/procedures for nursing assessment, medical record documentation, and occurrence reporting were followed and a registered nurse evaluated the nursing care of a patient for 1 of 11 medical records (patient 27) reviewed.

Findings:

1. The policy/procedure The Medical Record (approved 9-12) indicated the following: "The main purpose of the medical record is to accurately and adequately document ...events affecting the patient during the current episode of care."

2. The policy/procedure Assessment and Reassessment (approved 8-12) indicated the following: "Patients are assessed continuously throughout their hospital stay ...the charge nurse, RN, and/or LPN/LVN must document evaluations in an ongoing fashion (as they occur and /or after they occur)."

3. The medical record for patient 27 failed to indicate nursing assessment documentation on 12-10-14 for the period from 0700 hours to 1900 hours.

4. Administrative documentation dated 12-10-14 indicated that nursing staff N19 was assigned to provide care for patient 27.

5. During an interview on 3-24-15 at 0940 hours, the chief nursing officer A2 and director of quality A3 confirmed the medical record for patient 27 lacked nursing assessment documentation on 12-10-14 between 0700 hours and 1900 hours.

6. The policy/procedure occurrence/Event Reporting (approved 8-12) indicated the following: "An occurrence or incident is any event which is not consistent with the routine care of a patient or any circumstances that threaten the physical safety and well-being of patients ...any hospital employee or medical staff member who discovers the occurrence/event or is first on the scene has an obligation to begin the Occurrence Report process and complete it in a timely manner ...an occurrence/event report will be completed by the person discovering the event before leaving their assigned shift."

7. The physical therapy progress note dated 12-09-14 for patient 27 indicated the registered nurse postponed /cancelled the morning therapy session because of unexplained blood loss from a peripherally-inserted central catheter. Physician orders dated 12-09-14 at 0900 hours indicated priority laboratory and blood bank testing associated with the blood loss with orders to call the lab results to the physician.

8. On 3-24-14 at 0900 hours, the director of quality A3 was requested to provide documentation of an occurrence report associated with the 12-09-14 medical record entries for patient 27 and none was provided prior to exit.

9. During an interview on 3-24-15 at 0940 hours, the director of quality A3 confirmed that no occurrence report associated with the 12-09-14 medical record entries for patient 27 was available.