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Based on record review and interviews, the facility failed to develop and keep current nursing care plans to address the patients' needs for 7 out (ID #7, #9, #10, #12, #16, #18) 16 charts reviewed throughout the facility in the following units MICU, 3 Cullen, 5 Cullen, 8, 6 and 3 Jones, and CVIMU.

Findings Include:

Record review of the facility policy dated 05/27/2021 "Electronic Documentation: Interdisciplinary Plan of Care (IPOC) stated:
D. One (1) or more Focused IPOCs will be initiated.
E. Patient goals will be patient -focused, individualized, measurable, and prioritized, bridging the gap between hospitalization and home.

Record review on 01/03/2023 between 1030-1400 revealed the following:
Patient (ID#7) a paraplegic was admitted on 12/30/23 to MICU with a diagnosis of septic shock. Skin was not addressed in the IPOC.

Patient (ID#9) was admitted to 3 Cullen for a diagnosis of renal failure. Fluid overload was not addressed in the IPOC.

Patient (ID#10) was admitted on 3 Cullen for a diagnosis of acute sepsis. Sepsis was not addressed in the IPOC.

Patient (ID# 12) was admitted to 5 Cullen on 12/28/23 for Crohn's with a new diagnosis of HIV. The diagnosis of HIV was not addressed on the IPOC.

Patient (ID#16) was admitted to 6 Jones for neck cellulitis and uncontrolled diabetes. No patient teaching was noted related to diabetes in the IPOC.

Patient (ID#18) admitted to 3 Jones with a diagnosis of abdomen wall abscess, with a documented blood sugar of 299. Patient (ID#8) was scheduled to be discharged on the day of the visit. Diabetes was not addressed on the IPOC.

Interview with the charge nurses in MICU on 01/03/2024 between 1140-1530 (staff ID #70), 3 Cullen (staff ID #71), on 5 Cullen, (staff ID#73), 8 Jones (staff ID#74), 6 Jones (staff ID#76), 3 Jones (staff ID #79) all verified the finding during the record review on each unit.

Based on observation and interview the facility failed to promote a sanitary enviroment to avoid the transmission of infection by ensuring the 5 of 7 computers on wheels were clean in the observation unit.

Findings:

Record review of the facility policy dated 06/13/2019 stated Cleaning: The removal of all organic and foreign material, (soil, body fluids, blood, tissue) from objects. This is accomplished using water with detergents or enzymatics products.

Observation on 01/03/2024 of the observation unit on 8 Jones, revealed 5 of the 7 computers on wheels were covered with stickers around the computers screen enabling the computer to be cleaned between patients.

Interview with the staff (ID#68) during the observation, vertified the findings.