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Based on record review and interview, it was determined the facility failed to ensure all documentation by Registered Nurse (RN) and Registered Dietician occurred prior to the patients' discharge for the hospital. This affected Patient Indentifer (PI) #s 4 and 5 (2 of 2 discharged medical records) and had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 4 was admitted to the facility with diagnosis of Kidney Disease on 4/9/15 and was transferred to another acute care facility on 4/12/15.

Review of the Nursing Notes revealed a General Assessment Nurse Note dated 4/13/15 at 8:25 AM. The patient left the hospital on 4/12/15 at 7:30 PM.

An interview was conducted on 4/15/15 at 1:25 PM with Employee Identifier # 2, Director of Nursing Service who verified the above findings.

2. PI # 5 was admitted to the facility on 3/30/15 and was discharge to a Long Term Care facility on 4/2/15.

Review of the Nursing Notes revealed a General Assessment Nurse Note dated 4/2/15 at 6:00 PM. The patient left the hospital on 4/2/15 at 1:00 PM.

Review of the physician's order dated 3/30/15 revealed the patient was to receive a soft 2 gm (gram) sodium diet.

Review of the Initial Nutritional Assessment revealed it was completed on 4/9/15 (7 days after discharge). The Registered Dietician (RD) recommended a soft 2 gm sodium renal diet due to the patients kidney disease.

An interview was conducted on 4/15/15 at 1:30 PM with EI # 2 who verified the above finding. When the surveyor asked why the RD completed the Initial Nutritional Assessment 7 days after discharge, the response was, "The RD comes 1 time a month."

Based on record review and interview, it was determined the facility failed to ensure the Registered Dietician (RD) completed an Initial Nutritional Assessment prior to the patient's discharge. This affect Patient Identifier (PI) # 5 (1 of 1 records reviewed with an Initial Nutritional Assessment ) and had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 5 was admitted to the facility on 3/30/15 and was discharge to a Long Term Care facility on 4/2/15.

Review of the physician's order dated 3/30/15 revealed the patient was to receive a soft 2 gm (gram) sodium diet.

Review of the Initial Nutritional Assessment revealed it was completed on 4/9/15 (7 days after discharge). The RD recommended a soft 2 gm sodium renal diet due to the patients kidney disease.

An interview was conducted on 4/15/15 at 1:30 PM with EI # 2 who verified the above finding. When the surveyor asked why the RD completed the Initial Nutritional Assessment 7 days after discharge, the response was, "The RD comes 1 time a month."

Based on the review of the Rules and Regulations of the Medical Staff and medical record and interview, it was determined the facility failed to ensure the medical staff member countersigned verbal orders within 24 hours. This affected Patient Identifiers (PI) # 2 and 5 (2 of 5 records reviewed) and had the potential to affect all patients served by this facility.

Findings include:

Rules and Regulations of the Medical Staff

Section 4.2 - Physicians' Orders

4.2.1 - All orders for treatment shall be in writing. A verbal order shall be considered to be in writing if dictated to a Registered Nurse, to a Licensed Practical Nurse...

4.2.2 - Such orders shall be signed by the person to whom dictated, with the name of the staff member giving the orders per his or her own name, and countersigned by the staff member within twenty-four (24) hours.

1. PI # 2 was admitted to the facility on 4/13/15 with a diagnosis of dehydration. Review of the verbal order received from the physician by Employee Identifier (EI) # 22, Registered Nurse (RN) at 1:25 PM revealed no documentation of the physician countersigning when record was reviewed on 4/15/15.

2. PI # 5 was admitted to the facility on 3/30/15 and discharged 4/2/15.

Review of the verbal order dated 3/30/15 which was received from the physician by EI # 10, RN at 7:55 PM revealed no documentation of the physician countersigning when record was reviewed on 4/15/15.

Review of the verbal order dated 4/2/15 which was received from the physician by EI # 10, RN at 12:15 AM revealed no documentation of the physician countersigning when record was reviewed on 4/15/15.

An interview was conducted on 4/15/15 at 1:45 PM with EI # 33, Administrator who verified the physicians had 24 hours to countersign a verbal order.