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Based on record review, interview, and policy review, the facility failed to fully assess/evaluate 1 (#9) of 1 patient with a change of condition, in a total sample of 10, resulting in potential for less than optimal patient outcomes. Findings include:

Record review of patient #9's medical record, on 4/15/15 at 1130 with Nurse Manager #B, revealed that the patient had been transferred to the 2 West Step Down Unit on 3/10/15 from the High Acuity Unit/Medical Observation Unit (HAU/MOU). On 3/11/15 the patient had a condition change (difficulty hearing, blood pressure and irregular breathing), was seen by the physician and was to be transferred back to the MOU. The patient coded (breathing and heart stopped) on the Step Down Unit on 3/11/15 at 1936 as documented by the "Code Blue Flowsheet" with same date and time. It was noted that the patient's full nursing assessment was not documented for 3/11/15 between 0700 - 1930. There was was some documentation, but not a full nursing assessment. This was verified with the Nurse Manager on 4/15/15 at approximately 1200. The Nurse Manager stated, "It (a nursing assessment) should have been documented." The facility policy titled, "Assessment/Re-Assessment -- Interdisciplinary Patient", dated "2/2014", documented "Patients are re-evaluated by a licensed nurse...at a minimum every 12 hour shift based on level of care and patient care needs". This had not been done.

Based on record review and interview, the facility failed to update and implement a care plan for 1 (#9) of 1 patient with a change in status, out of a total sample of 10, resulting in potential for less than optimal patient outcomes. Findings include:

Record review of patient #9's medical record and interview with the Chief Clinical Officer, on 4/15/15 at 0930, revealed that in the Physician "Progress Note" dated 3/11/15 at 1235, the physician wrote "I have placed an order for the patient to possibly be transferred to MOU (Medical Observation Unit/High Acuity Unit) if the patient continues to hemodynamically decline. On 3/11/15 the "Nurses Notes" dated 3/11/15 at 0700 and 1100 documented, "sinus tachycardia" at a rate of 124 and 126 beats per minute, respectively.

Interview with Nurse #J, on 4/15/15 at approximately 1030, revealed that she could not auscultate (hear) the patient's blood pressure during her shift, nor did she document the respirations (rate or character). When queried about the respirations, Nurse #J stated, "they were agonal breaths" and she imitated the breathing. When queried what she did about that, the nurse stated, "I told the CNA (nurse assistant) to page Respiratory." There was no documentation that Nurse #J updated or implemented the care plan for a higher level acuity of care. The patient was resuscitated as per the "Code Blue Flowsheet" dated 3/11/15 at 1936, was stabilized, and transferred to the MOU.