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Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current, an individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice is evidenced by the failure to update the nursing care plans on 3 (#1, #2, #3) of 3 (#1-#3) sampled patients reviewed for completed and updated nursing care plans.
Findings:

A review of facility policy number POC-43 titled, "Treatment Planning," revealed in part, under the section Guidelines of Treatment Plans, Item 3.1 The treatment plan shall be an accurate and functional representation of the patient's treatment experience. 3.4 The treatment plan shall identify interventions developed to assist the patient in achieving goals. 6.0 A review of the patient's Treatment Plan following any major clinical change shall be conducted, and appropriate modifications made.

A medical record review on 11/06/2023 at 2:53 p.m. revealed Patient #1 had pedal edema identified on the history and physical completed on 11/03/2023 at 5:53 p.m. by the provider. There was no documentation indicating patient #1's nursing care plan had been updated to include this medical diagnosis or treatment interventions.

In an interview on 11/06/2023 at 3:00 p.m. S1DR confirmed there had been no update to Patient #1's nursing care plan.

A medical record review on 11/06/2023 at 1:00 p.m. revealed Patient #2 had pain and infected wound identified in the provider's progress notes. There was no documentation indicating patient #2's nursing care plan had been updated to include this medical diagnosis or treatment interventions.

In an interview on 11/06/2023 at 2:00 p.m. S1DR confirmed there had been no update to Patient #2's nursing care plan.

A medical record review on 11/06/2023 at 3:45 p.m. revealed Patient #3 had pain to back and lower extremities identified on the provider's progress notes. There was no documentation indicating patient #3's nursing care plan had been updated to include this medical diagnosis or treatment interventions.

In an interview on 11/06/2023 at 4:15 p.m. S1DR confirmed there had been no update to Patient #3's nursing care plan.

Based on record review and interview, the hospital failed to ensure medications were administered as ordered. The deficient practice is evidenced by failure to administer pain medication as ordered in 3 (#1, #2, #3) of 3 (#1-#3) reviewed patient records.
Findings:

Review of the medical record for Patient #1 revealed Motrin 800mg every 6 hours as needed for pain 1-3/10 was administered on 11/03/2023 at 8:54 a.m. for pain 8/10; on 11/04/2023 2:23 p.m. for pain 10/10; on 11/05/2023 at 9:22 a.m. for pain 8/10; on 11/05/2023 at 6:25 p.m. for pain 8/10. Furthermore documentation was not in the medical record that the provider was notified that Patient #1's pain level was greater than 3 when Motrin was administered.

In an interview on 11/06/2023 at 2:30 p.m. S1DR verified that the nurse didn't follow the PRN parameters to administer Motrin or notified the provider that Patient #1's pain was greater than 3 on a pain scale of 1-10.

Review of the medical record for Patient #2 revealed an order for Motrin 800mg every 6 hours as needed for pain 1-3/10. Motrin was administered 08/26/2023 11:09 p.m. for pain 10/10, 08/27/2023 2:47 p.m. for pain 10/10; 08/28/2023 8:24 a.m. for pain 10/10, 08/28/2023 5:32 p.m. for pain 10/10; 0 and on 8/29/2023 8:10 p.m. for pain 6/10. Furthermore documentation was not in the medical record that the provider was notified that Patient #2's pain level was greater than 3 when Motrin was administered.

In an interview on 11/06/2023 at 3:30 p.m. S1DR verified that the nurse didn't follow the PRN parameters to administer Motrin or notified the provider that Patient #2's pain was greater than 3 on a pain scale of 1-10.

Review of the medical record for Patient #3 revealed an order for Motrin 800mg every 6 hours as needed for pain 1-3/10. Motrin was administered on 11/03/2023 12:17 p.m. for pain 4/10. Furthermore documentation was not in the medical record that the provider was notified that Patient #3's pain level was greater than 3 when Motrin was administered.

In an interview on 11/06/2023 at 4:15 p.m. S1DR verified that the nurse didn't follow the PRN parameters to administer Motrin or notified the provider that Patient #3's pain was greater than 3 on a pain scale of 1-10.