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Based on medical record review and staff interview, the facility failed to develop comprehensive care plans to direct patients' nursing care needs. This deficient practice had the potential to negatively effect three patients (#3, #7, and #9) of a sample of 10 patients reviewed for comprehensive plans of care. The facility census was 114.

Findings include:

1. Review of the medical record revealed Patient #7 was admitted to the facility on 10/13/15 for surgical reversal of a colostomy. The medical record revealed the patient underwent abdominal surgery on 10/13/15. Observation conducted on 10/15/15 at 10:07 AM for wound care revealed the patient had a midline surgical incision as well as a lateral incision to the left mid abdomen. Both incisions were closed with surgical staples and required nursing care per a physician's order. Additionally, the patient was observed to have a urinary indwelling catheter for the draining of urine. Review of the patient's plan of care used by nurses to deliver comprehensive care failed to document a plan of care to direct the nurses on care for the prevention of infection in relation to the incisions nor the maintenance of the patient's urinary catheter.

Interview with Staff G on 10/15/15 at 1:57 PM verified the patient's current plan of care was not reflective of the patient's care needs.

2. Review of the medical record for Patient #9 revealed the patient was admitted to the facility on 10/13/15 with diagnoses which included acute and chronic respiratory failure and an exacerbation of chronic obstructive pulmonary disease (COPD). Review of the medical record revealed the patient was admitted with two pressure sores to the buttocks area. The patient was ordered a wound care consult which was completed on the morning of admission on 10/13/15 at 9:37 AM by the wound nurse. The patient's pressure wounds were documented as a stage II pressure ulcer measuring 0.3 centimeters (cm) width by 0.3 cm length and less than 0.1 cm depth on the coccyx. A second pressure wound was present at time of assessment in the crease of the buttocks, which was documented as 0.2 centimeters wide by 0.1 cm long and a depth of less than 0.1 centimeters. The wound care nurse directed the areas should be covered with an Allevyn (foam with a border) dressing.

The medical record revealed Patient #9 had a plan of care for knowledge deficit related to the exacerbation of COPD only. Interview with Staff G on 10/15/15 at 2:47 PM verified the facility was unable to provide a nursing plan of care that directed nurse in the provision of care for Patient #9's malnutrition and pressure ulcers.

3. Review of the medical record for Patient #3 revealed a nursing admission assessment, dated 08/25/15 at 4:27 PM that documented Patient #3's pulse was 117. Review of the nurses notes, dated 08/25/15 at 6:31 PM, revealed Vicodin (relieve moderate and severe pain), 5/325 milligrams (mg), two tablets, by mouth (po) and gabapentin (medication for restless leg syndrome), 300 mg, one tab, po was administered for complaints of pain and neuropathy. Review of the nurses notes from 08/25/15 to 08/28/15 revealed Patient #3 complained of nausea and pain during the patient's stay in the facility. Further review of the notes revealed Patient #3 had recurrent emesis and a poor intake of food and fluids.


Review of the care plan for Patient #3 revealed the only care planned for this patient was knowledge deficit related to cellulitis, medications for pain nausea and antibiotics and intravenous fluids.

Interview with Staff B on 10/15/15 at 10:00 AM confirmed knowledge deficit was the only care plan in the record.



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