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Based on record review and interview the facility failed to implement a Plan of Care based on the initial assessment for 1 out of 1 patients (patient # 1). These findings have the potential to cause harm to all patients receiving care at the hospital by failure to implement and follow the plan of care.

Review of the medical record on 04/21/2011 for patient # 1, revealed the patient was admitted on 08/04/2010 at 2230 and the initial nursing assessment was completed on 08/04/2010 (No time recorded). The assessment indicated the patient was nutritionally at risk. The documentation revealed that that the Registered Nurse documenting the assessment documented she requested a nutritional consult. There was no evidence the nutritional assessment was conducted until 08/11/2010.

Review of the facility policy titled "Nutritional Screening and Assessment" last revised on 11/01/2010 page 1 (under nursing procedure) states " a nutritional risk screen is completed on the nursing assessment form with in 24 hours of admission. A nutritional assessment consult is sent to the Registered Dietician when any of the criteria in the nutrition risk screen is checked. 1.0 After receiving the referral from the nutritional risk screen, appropriate nutritional intervention it initiated. The nutritional assessment is completed within 24-48 hours after the referral has been received. The policy also states at 3.0 states the dietician is to be consulted for nutrition risk for length of stay greater than 6 days and for new TPN (Total Parental Nutrition) order.

Review of the medical record on 04/21/2011 revealed the dietician preformed an assessment 7 days from the date of admission on 08/11/2010 and continued to followed the patient on 08/12/2010 and documented a total KCAL of 215 in 24 hours. On 08/16/2010 the dietician documented the patient's TPN was reduced to 40 Milliliters (ml) per hour and the total calorie counts was difficult to obtain due to family bring food from home and that the patient was a poor historian. There was no evidence documented the family was educated on recording the amount of food eaten to assist the dietician in determining the needs of the patient. There is a third page that the dietician documented on and recorded a KCAL of 150. There is no evaluation documented by the dietician to assist the other heath care team to know and understand if the patient was receiving adequate nutrition, in addition there was no evidence the dietician included his recommendation or initiated or revised the nutritional plan of care. There is no further documentation or revision of the plan of care to assist this nutritional at risk patient through the date of transfer to a higher level of care on 08/25/2010.

Review of the order entry system used to communicate orders to the Dietician revealed there was no order entered in the system for the nutritional consult. There was no indication the nurse followed through by implementing the plan of care for this nutritionally at risk patient at the time of the assessment on 08/04/2010.

Interview with the Dietician and the Director of Nurses on 04/21/2010 at approximately 09:30 a.m. confirmed the above findings.

Based on record review and interview the facility failed to follow the physician order in the administration of Coreg 12.5 Milligrams (mg) in 1 out of 1 patient records reviewed (Patient # 1). These findings have the potential to cause harm to all patients receiving medications in the facility by the facilities failure to follow the physician instructions. In addition review of the admitting orders revealed the physician ordered vital signs to be taken every 4 hours.

Review of the medical record for patient # 1, on 04/21/2011, revealed that the physicians ordered Coreg 12.5 mg on 08/10/2010. The instructions for administration stated "hold the medication if the heart rate is below 60 and the systolic blood pressure is below 100. On the medication record on 08/23/2010 the medication is stamped DISCONTINUED in capital letters, there is no time to indicate when it was discontinued on the record. Review of the physicians order revealed there was not a physicians order to discontinue the medication. On 08/23/2010 the medication was administered at 0900 a.m. by the morning nurse. The medication record contained the warning to hold the medication if the heart rate was below 60 and systolic blood pressure below 100. There was no indication the nurse took the pulse or the blood pressure prior to administration.

Review of the nurse ' s notes and the vital sign recorded on 04/21/2010, revealed that on 08/23/2010 the morning nurse did not record any vital signs on the vital signs record or nurses note. I addition there was no documentation to indicated the pulse or blood pressure was taken at or before the 9 am dose of Coreg 12.5 mg. In addition the vital signs are not recorded in the section of the graphic for 8 am or 12 noon on 08/23/2010.

Interview with the Director of Nurses on 04/21/2011 at approximately 10:30 a.m. confirmed the above findings.