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Based on facility policy and procedures, a medical record review, and staff interviews, it was determined that nursing staff failed to develop and maintain a care plan based on an accurate assessment of care needs for one patient (P) #1 out of two sampled patients (P#2 and P#3). Specifically, P#1's initial nursing assessment did not include diabetes, nor was P#1's care plan updated to include diabetes throughout P#1's hospital stay.

Findings included:

A review of the facility's policy titled "Nursing Assessment and Reassessment of Patients," Version 4, reviewed 12/18/20, revealed that nurses who interacted with patients during treatment were responsible to assess and reassess the patient's condition and care needs. Assessment was defined as the process of collecting and interpreting patient-focused data to match individual needs to the appropriate setting, care level, and interventions. The initial assessment would be completed by the nurse as soon as possible after admission, according to the timeframes defined by each unit. Medical units would complete the initial nursing assessment within 30 minutes of admission. The initial nursing assessment would include assessing the various systems. An admission database would be completed by the nurse within 24 hours of admission, including patient information, healthcare directives, belongings, vital signs, problem list, procedure history, family history, medication list, etc. A nursing reassessment would be performed and documented each shift. Periodic reassessments would be performed more frequently as needed.

A review of the facility's policy titled "Nursing Policies and Procedures, Version 2", last reviewed on 12/18/20, revealed that the policy outlined the process and expectations when utilizing Lippincott Procedures. It was intended to be utilized as a reference tool for accessing evidenced-based practices for procedures within the clinical setting. "Lippincott Procedures" was a software program that provided evidence-based standards of patient care. While Lippincott Procedures offered guidance to clinical team members in carrying out clinical procedures and served as a reference for directing care, team members were required to adhere to the facility's policies and procedures. As with any general resource, not all available content in the Lippincott Nursing Procedures would apply to the facility's services. Staff members were to notify the Nursing Administration of discrepancies between facility policy and Lippincott procedures to ensure the facility was in alignment with evidence-based practices.

A review of the Lippincott Care Plan Preparation guidelines revised 5/20/22, revealed that a care plan directed a patient's nursing care from admission to discharge. The care plan would be based on nursing diagnoses that had been formulated after reviewing assessment findings. A nursing care plan would be written for each patient, preferably within 24 hours of admission. If a patient had just been admitted, a nursing history and physical assessment would be added to the patient's record. Diagnoses to guide patient care would be based on the analysis of data. Nurses would evaluate the patient's progress and revise the care plan as appropriate.


A medical record review revealed that Patient (P) #1 was transferred to the facility from an area Emergency Department (ED) due to abnormal outpatient laboratory test results. Hospitalist progress notes by Medical Doctor (MD) GG on 4/27/23 at 11:29 a.m. revealed that an affiliated ED requested a transfer to the facility for nephrology (kidney) and cardiology (heart) evaluation. P#1 was admitted as an inpatient for observation on 4/27/23 at 9:10 p.m.

A review of the affiliated ED physician's discharge assessment revealed that P#1 had a history of diabetes. The ED discharge nursing assessment failed to reveal that P#1 was diabetic. A review of a transfer form revealed that the ED records were sent to the receiving facility.

A review of a History and Physical by MD HH on 4/27/23 at 8:58 p.m. revealed that P#1's chief complaint was weakness. P#1's past medical history was obtained from P#1 and the medical record. P#1 had a history of chronic kidney disease, diabetes, high blood pressure, atrial fibrillation (irregular heart rhythm), and stroke. Home medications included Lantus (insulin for diabetes) at bedtime and Novolog (insulin for diabetes) three times daily before meals.

A review of nursing documentation by the night-shift Registered Nurse (RN) II on 4/27/23 at 9:55 p.m. revealed that electronic orders had been reviewed, the medication list had been reconciled, and the problems/histories had been completed. The nursing documentation failed to reveal that P#1 was diabetic.

A review of a plan of care initiated on 4/28/23 at 4:00 a.m. by RN II revealed the only problem identified was a risk for falls. The plan of care failed to include diabetes or other medical problems. A review of the plan of care through 5/1/23 at 8:44 a.m. revealed the plan of care was reviewed but not updated throughout admission.

An interview occurred with Nurse Manager of 5 Tower (NM) BB on 5/16/23 at 3:04 p.m. in the Conference Room. NM BB stated nurses would do an initial head-to-toe assessment and admission database, which included the social history, procedures, nutritional screening, and past medical history. Information would be obtained through interviewing the patient, and if the physician's history and physical assessment were signed, it could also be used as a reference.

An interview occurred with the day shift RN CC on 5/16/23 at 3:51 p.m. RN CC stated that P#1's family member told RN CC that P#1 was diabetic the afternoon of 4/28/23. RN CC said that sometimes nurses read through the patient history later in the afternoon, and RN CC had not gone through the file prior to the blood sugar check on 4/28/23 at 2:41 p.m. RN CC further said that head-to-toe nursing assessments took place in the mornings. RN CC explained that a care plan was when the nurses planned what to do and what they planned to achieve, then the plan would be executed. Diabetes would have been included in the care plan. RN CC said the care plan would have been started within 30 minutes of P#1's admission.

A telephone interview occurred with the Chief Nursing Officer (CNO) EE on 5/17/23 at 11:30 a.m. CNO EE said that depending on the unit and severity of the patients, the nurses would initiate a history, assessment, and discussion with the physicians to determine the plan of care. When patients came onto the unit, the nurses had a couple of hours to get admission information and history from the patient. There was a little more time for a full assessment. If a patient had been in the hospital organization previously, the nurses would have historical data in the computer, or a support person may have information. Authenticated (signed) documentation by the physician could also have provided a patient's history. CNO EE said nurses would do a handoff (information about a patient given during a change of care from one facility, unit, or nurse) with a phone report from the transferring department or facility. The handoff would be documented on a transfer form. Reports would also be given from nurse to nurse during shift change. If a patient had diabetes, the nurse would follow up with the provider.

A telephone interview occurred with RN II on 5/23/23 at 11:06 a.m. RN II said her first day at the facility was 4/17/23, and she was just off orientation when P#1 came to the unit. RN II said there was no handoff from the sending hospital on her shift. RN II said the handoff likely occurred before the evening shift. RN II said she got the report from the day shift nurse and did not remember diabetes mentioned during the report. RN II said patients would come with a record from the ED. The doctor would do a history and physical, and the nurse could call the family members for additional information if the patient were unable to speak. RN II said an initial assessment would be done within an hour of arriving at the unit. Reviewing the MD assessment would be part of the nursing assessment. RN II said a care plan would be initiated within an hour or two of the patient's arrival and updated at least once per shift. Diabetes would have been part of the care plan.