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Based on observation, record review and interview of nursing plans of care revealed that nursing failed to evaluate each patient individually (ID#1, 3,5,6,7,8) to address their specific needs.

Findings Included:

Record review of the hospital policy dated 05/2025. "Support: Interdisciplinary Plan of Care" Purpose: To provide each patient with an individualized, plan of care, to determine priorities and to assist the patient in establishing achievable goals.

Observation and record review on 06/13/2025 between 1115- 1215 of nursing care plans with the charge nurses on IMCU (ID# F) and IMU (ID#E), revealed the following:

Patient (ID#1), who was admitted for sepsis and hypokalemia. Plan of care was vague, stating the problem of "infection alteration as the problem" expectation was for it to improve. Nothing else stated.

Patient (ID#3) was admitted for infection of left foot and had a history of diabetes.
Interview on 06/13/2025 at 1145 with the charge nurse (ID #H) stated the patient (ID#3) was depressed, but it was not addressed in the plan of care.

Patient (ID#5, 6, 7, 8) were over 70 and their plan of care was also vague and did not address the patients' specific needs related to ambulation, and possible infection.

Interview during chart review on 06/13/2025 on the specific units with charge nurse (ID#H) of the IMCU at 1115 and charge nurse (ID#E) of IMU at 1215, both validated the findings.