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Based on record review, facility policy and procedure review and staff interview the facility failed to develop a plan of care to meet the needs of 9 of 20 sampled inpatient records (Patient 1,3,4,7,8,9,14,19 and 20). This has the potential to have the patient's care needs unmet during their hospital stay. The facility inpatient census was 4 on entrance 7/13/15. The total sample was 42 with 20 records of inpatients reviewed.

Findings are:

A. Review of the facility Policy and Procedure for care planning titled "Adult Patient Standards of Care Effective date: 7/1/15" under the section titled "Interdisciplinary Care, The Plan of Care" states "1. Planning for care, treatment, and services is individualized to meet the patient's unique needs. Initiation and creating the plan of care is begun on admission." and "2. To continue meeting the patient's unique needs, the plan is maintained and revised based on the patient's response at a minimum once daily."

B. Record review of Patient 9's medical record revealed the patient was admitted on 4/28/15 for a right total knee replacement surgical procedure. The patient discharged to home on 5/1/15. Review of the facility Electronic Medical Record (EMR) form identified as IPOC (Interdisciplinary Plan of Care) notes that on 4/29/15 Acute Pain was identified with goals and interventions to address the patients pain. The IPOC was updated 5/1/15. The IPOC did not identify the presence of a surgical wound or the mobility interventions needed for this patient.
Staff interview with Registered Nurse (RN) B on 7/16/15 at 4:10 PM confirmed the IPOC did not reflect the patient's needs,

C. Record review of Patient 14's EMR identified an admission date of 7/6/15 for upper respiratory infection with low oxygen levels and decreased level of consciousness. Review of nursing assessment documentation on admission 7/6/14 at 7:00 PM noted the patient was total care, confused, and non ambulatory due to prior double above the knee amputations. The fall risk score assessed on 7/6/15 noted the patient was at high risk for falls. The Braden (skin breakdown risk assessment tool) identified the patient to be at high risk related to moisture, 2 person assist and reddened skin on coccyx (tailbone area). Review of physician admission orders 7/6/15 noted the patient required IV (Intravenous)Antibiotics, Diuretics to reduce fluid overload, Oxygen and Physical Therapy. Review of the IPOC last updated 7/11/15 contained only the problem of impaired skin integrity with interventions. The patient discharged on 7/15/15 back to the nursing home.
Staff interview with RN C, a Senior Nursing Manager, on 7/15/15 at 10:20 AM revealed RN C would have "expected high fall risk, impaired gas exchange" to be included in the IPOC and "did not find it.'

D. Record review of Patient 19's EMR revealed the patient was admitted on 1/1/15 with bilateral leg pain after a fall. Admitting diagnosis per the history and physical dated 1/1/15 also identified the patient had dementia, dehydration, shock. Review of physician orders dated 1/3/15 identifies the goal of comfort care for a "natural death." The patient was identified with orders and advance directive on admission as a Do Not Resuscitate (DNR). Review of the IPOC initiated 1/2/15 and last updated 1/8/15 identified only pain as a problem with goals and interventions. The patient died 1/9/15.
Staff interview with RN B on 7/14/15 at 4:20 PM revealed RN B "expect oral care, ADL [activities of daily living] care to reflect the comfort cares the patient required.

E. Record review of Patient 20's EMR revealed the patient was admitted on 5/3/15 for abdominal pain with lung cancer, liver cancer and pancreatic cancer. Admission physician orders and History and Physical dated 5/3/15 identified the patient's need for IV pain control and dehydration. The patient was a DNR on admission per orders and advance directive. Review of nursing documentation on 5/7/15 noted the patient became unresponsive with a Glasgow Coma Score (GCS) of 3. The GCS rates a patient's level of consciousness from 3 -15 with 15 being fully alert and oriented. A score of 3 -8 is a patient in a coma. Review of the IPOC developed on admission and last updated 5/8/15 identifies only impaired gas exchange as a problem with interventions. The patient died on 5/8/15.
Staff interview with RN B on 7/14/15 at 4:40 PM confirmed the pain management needs, identified on admission, or any interventions related to the comfort cares the patient needed were not included in the IPOC as expected.




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F. Patient 1 was admitted on 7/1/2014 for severe pain in the right arm. EMR review revealed Patient 1 had incision and drainage of an abscess of the right elbow on 7/1/2014. Review of the IPOC for this patient dated 7/1/2015 included "Fall Risk". "Nutrition", and "Friction/Sheer" as the problems in the plan. The IPOC did not address pain that was the reason the patient came to the facility, nor did it identify infection as a problem when the cause of the pain was an abscess that required surgical incision and drainage. The patient did have medications ordered by the physician for pain and antibiotics for the infection. Despite this, the plan did not address the pain or the infection the patient was diagnosed as having.
The RN [RN-C] assisting with review of the record on 7/16/2015 at 3:00 PM confirmed the failure to include these areas in the IPOC and verified they should have been addressed in the IPOC.

G. Patient 3 was admitted on 1/5/2015 with abdominal and back pain per the EMR. Tests revealed the patient had appendicitis. Surgery was performed [Laparoscopic appendectomy] to remove the appendix through small incisions with a scope and camera technique. Review of the IPOC on 7/16/2015 revealed 1 problem identified. The problem identified was pain. The IPOC failed to have any problem related to surgical wound risk for infection, or safety risk of injury following use of anesthesia.
RN-C verified the IPOC did not address the needs of the post surgical patient on 7/16/2014 at 3:15 PM during the record review.

H. Patient 4 was admitted on 4/20/2015 with a non healing ulcer on the stump of a right below the knee amputated lower extremity. The EMR noted the patient underwent surgical revision of the stump resulting in an above the knee amputation of that extremity. Review of the IPOC on 7/16/2015 revealed problems identified as "Risk of Fall or Mobility Injury", "Risk of Bleeding",and "Acute Pain". The IPOC did not address surgical wound, skin integrity or risk of infection.
Interview with RN-C on 7/16/2015 at 3:25 PM confirmed the IPOC did not address these areas and the IPOC should have addressed them for this patient's care.

I. Patient 7 was admitted on 6/15/2015 with osteoarthritis of the left hip. The EMR noted the patient underwent a total knee replacement on 6/15/2015. Review of Patient 7's IPOC revealed problems identified included "Risk of Fall or Mobility Injury", and "Self-Care Deficit". The IPOC did not address pain, risk of infection, or surgical wound.
An interview with RN-C on 7/16/2015 at 3:30 PM during the record review confirmed pain, risk of infection, nor surgical wound were included in the IPOC and should have been addressed in the IPOC.

J. Patient 8 was admitted on 3/13/2015 with a traumatic fracture of the left hip. The EMR noted the patient had surgical repair with total left hip replacement performed. Review of the IPOC found problems identified included "Risk of Fall or Mobility Injury", "Self Care Deficit", and "Pain". The IPOC did not address risk of infection or skin integrity related to a surgical wound.
An interview with RN-C on 7/16/2015 at 4:00 PM confirmed the IPOC did not have risk of infection or address the surgical wound and that the IPOC should have addressed these areas of care needs.

Based on record review and administrative staff interview 5 of 5 Swing Bed records (Resident 32, 33, 34, 35, and 36) failed to have a comprehensive, standardized assessment of the resident's functional capacity initiated on admission. This finding has the potential to cause staff to fail to identify and provide care/services to meet the needs of the resident based on their current level of functioning. The Swing Bed census was 1. The total Swing Bed sample size was 5, which included 4 closed records.
Findings are:

A. Record review of the current Swing Bed Resident 36 admitted on 6/26/15 and closed record review of the medical records for Resident 32 (admitted 1/12/15 and discharged 1/22/15), Resident 33 (admitted 3/4/15 and discharged 3/17/15), Resident 34 (admitted 3/16/15 and discharged 3/25/15), Resident 35 (admitted 5/16/15 and discharged 5/19/15) revealed all failed to have a comprehensive standardized assessment of the resident's functional capacity initiated on admission.
B. Administrative interview on 7/22/14 at 3:00 PM with Social Worker (SW) A, who is also the Swing Bed coordinator, revealed the facility does not have a comprehensive standardized assessment form that contains and documents the resident's functional capacity initiated on admission. SW A also confirmed the facility does not have a policy regarding the initiation or completion of a comprehensive assessment for Swing Bed residents.

Based on record review and administrative staff interview the facility failed to complete a comprehensive assessment within 14 days of admission for 1 of 1 (Resident 36) Swing Bed sampled residents with a length of stay longer than 14 days. This finding has the potential to cause staff to fail to identify and provide care/services to meet the needs of the resident based on a completed comprehensive assessment of their current level of functioning. The facility Swing Bed census was 1. The total Swing Bed sample size was 5, including 4 closed records.
Findings are:

A. Record review revealed Resident 36 was admitted on 6/26/15 after an acute hospital stay for Sepsis, a severe infection spread through the bloodstream. The record failed to have a comprehensive assessment completed by the 14th day (7/9/15) as required.
B. Administrative staff interview on 6/26/15 at 3:00 PM with Social Worker A, who is also the Swing Bed Coordinator, confirmed the facility did not have or complete a comprehensive assessment which included all the required assessments of the resident's functional status. SW A further related that the facility does not have a policy for the initiation or completion of a comprehensive assessment by the 14th day of admission. SW A stated "we rarely have anyone here more than 14 days."