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Based on review of records and interviews on 3/9/2018, the facility failed to develop and keep current nursing care plans to address the patients' needs for 2 of 11 patients (Patient # 7 and 11) on the 6th floor.

Findings:

Record review on 3/9/2018 of patient (ID# 7) revealed the patient was admitted on 3/1/2018 with the diagnoses of unstable angina. The patient did not have a plan of care initiated.

Record review on 3/9/2018 of patient (ID# 11) revealed the patient was admitted on 3/7/2018 with the diagnoses of pyelonephritis, sepsis and a history of diabetes. The plan of care was implemented on 3/7/2018 but did not address alteration in fluid and electrolyte imbalance or diabetes.

Interview on 3/9/2018 at 1205, with staff (ID #60) RN, she stated the care plans should reflect the patient's current problems and completed at admission and updated every shift (every 12 hours).

Record review of a Park Plaza policy entitled "Admission Assessment and Re-Assessment, " (revision date 7/15) revealed all patients shall be assessed by an RN on admission to the hospital and shall be reassessed by an RN at least daily.

F. Problem Identification:
1. The RN assessment shall determine the initial problem list, which is documented on the Care Plan form.
2. Based on all aspects of the data collection during the initial assessment, the RN is responsible to evaluate and integrate the information collected, including the physician 's orders and the history and physical.
4. The policy also stated that each problem will have common interventions to be checked and measurable goals.

Based on observation, interview and record review on 3/9/2018, the facility failed to ensure direct care staff maintained the principles and practices for preventing transmission of infectious agents within the hospital.

This failed practice had the potential for the spread of infection to all patients on census. Citing four (4) random observations of staff (ID # 54, 55, 56 and 58) entering patient rooms (patient ID # 2, 3, 6).

Findings include:

On 3/8/2018 at 0950 RN, (registered nurse) staff (ID# 56) was observed going in patient (ID # 2) room without utilizing the alcohol-based hand rub before going into the room.

On 3/8/2018 at 1000 RN, staff (ID# 54) was observed going in patient (ID # 3) room without utilizing the alcohol-based hand rub before going into the room.

On 3/8/2018 at 1210 Certified Nurses Assistant staff (ID# 58) was observed going in patient (ID # 6) room without utilizing the alcohol-based hand rub before going into the room.

On 3/8/2018 at 1210 RN, staff (ID# 55) was observed going in patient (ID # 6) room without utilizing the alcohol-based hand rub before going into the room.

Record review of the facility's current policy "Hand Hygiene" dated 2/2012 stated 3. If hands are not visibly soiled, used an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations.

Interview on 3/8/2018 at 1230 with CNO (Chief Nursing Officer) (staff ID #57), she stated staff should gel in out when entering and leaving a patients' room.