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Based on observations, staff interview, medical record review, policy review, and facility guidelines review, the facility failed to ensure that the nursing staff develops, and keeps current, a 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 (A396).

Based on observations, staff interview, medical record review, policy review, and facility guidelines review, the facility failed to ensure that the nursing staff develops, and keeps current, a 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 for eight of 11 patients reviewed (Patient #1, #3, #4, #5, #6, #8, #9 and #13. The hospital census was 542.

Findings include:

1. Review of the medical record for Patient #1 revealed the patient was brought in by ambulance to the emergency department (ED) on 06/27/22 at 2:15 PM from an extended care facility (ECF). The primary diagnosis was vaginal bleeding. Patient #1 also had a history of atrial fibrillation (A-fib). Patient #1 was alert and oriented and responsible for herself. The patient was started on telemetry to monitor her heart rate/rhythm. She was discharged from the hospital on 07/05/22 at 2:42 PM to a skilled nursing facility.

Review of patient's medical record revealed a rhythm strip was run on 06/29/22 at 12:56 PM and 06/29/22 at 3:18 PM. These were the only two rhythm strips in the patient's record.

Review of Patient #1's vital signs revealed on 07/01/22 her pulse was documented four times between 7:00 AM and 7:00 PM. On 07/02/22 from 12:26 PM to 7:55 PM there was no documentation her heart rate was monitored. On 07/04/22 her pulse was document two times between 7:00 AM and 7:00 PM. There was no further documentation of the patient's pulse/heart rate throughout her hospitalization.

Review of the document titled, Guidelines for Advanced Care Units Routines and Documentation, effective 06/30/22, revealed the objective guidelines are to be used as a reference tool to help nurses with unit expectations and frequencies in which nursing care should be delivered on each unit/cluster. All patients admitted into advanced care units the specific orders override the guidelines. Specific unit guidelines for more frequent nursing assessments, routines, and documentation override these guidelines. A shift is defined as a 12 hour shift. Many of these care guidelines are a summary of nursing care addressed in individual policies. The procedure for vital signs included heart rate (if continuous monitor), respiratory rate, Sp O2 (if continuous), and cardiac rhythm (if continuous monitor) six times per shift (recommended to complete every two hours) and as needed. If a patient is not on continuous electrocardiogram (ECG) or Sp O2 monitor, record heart rate and Sp O2 three times per shift, unless specified differently in orders. For continuous ECG monitored patients print and document a rhythm strip on admission, every shift, as needed with any rhythm changes, and with any changes in the primary registered nurse (RN) assuming care for the patient, unless provider ordered differently.

Review of the intravenous (IV) flow sheet revealed Patient #1 had a 20 gauge IV placed to her right antecubital area on 06/27/22 at 2:43 PM. It was discontinued on 07/05/22 at 2:41 PM. Review of the of medical record and the flow sheet revealed no documentation the dressing to Patient #1's IV site was ever changed during her hospitalization from 06/27/22 to 07/05/22.

Review of the document titled, Guidelines for Advanced Care Units Routines and Documentation, effective 06/30/22, revealed under General Routines, peripheral IV dressings are to be changed every Wednesday and as needed.

Review of the policy and procedure titled, Nursing Services Intravenous (IV) Therapy, effective date 10/03/19, revealed all dressing changes will be performed every Wednesday and as needed regardless of insertion date.

Review of the medication administration record (MAR) revealed on 06/30/22 at 6:20 AM Patient #1 was given Tylenol (analgesic) 650 milligrams (mg). There was no documentation of the pain location or the pain scale at this time. On 06/30/22 at 7:27 AM Patient #1 rated her pain a "10" and the location was her head. There was no documentation any pain medication was given until 9:52 AM for head pain. The pain scale was not documented and there was no post assessment completed. On 06/30/22 at 4:42 PM, 7:36 PM, and 11:00 PM was documented zero pain; 07/01/22 at 9:14 AM rated head pain a "10" and Norco (opioid analgesic) 5/325 mg two tablets was given. There was no post assessment documented. On 07/01/22 at 4:44 PM no pain; 8:22 PM rated pain to buttocks a six. Norco was given at 8:22 PM for moderate/severe pain; post assessment at 9:21 PM was documented zero pain; 07/02/22 at 6:03 AM zero pain; 7:53 AM zero pain; 7:55 AM zero pain; at 9:04 AM two tablets of Norco for moderate to severe pain was given. There was no pre or post pain assessment and there was no follow up for the pain; 10:15 PM zero pain; 11:07 PM zero pain. There was no further documentation of pain until 07/05/22 at 5:52 AM when Patient #1 complained of bilateral foot pain and rated the pain a seven. Norco 5/325 mg two tablets was given. The post assessment at 6:46 AM was zero pain.

Review of the document titled, Guidelines for Advanced Care Units Routines and Documentation, effective 06/30/22, revealed assessment guidelines included a pain assessment completed with head-to-toe assessments, if pain medication is given, reassess pain and document new pain assessment within one hour.

Review of the policy and procedure for Pain Assessment, effective date 03/21/21, revealed pain reassessments are performed 60 minutes after pharmacological or nonpharmacologic intervention administered.

Review Patient #1's nutrition status revealed on 06/28/22 at 12:AM she had an order for a cardiac diet and then at 12 15 AM was changed to a diabetic diet, medium calorie level; 1600 1900 calorie. On 06/28/22 there was documentation Patient #1 fed herself for all three meals; on 06/29/22 she was nothing by mouth (NPO) due to surgery and then on 06/30/22 at 6:56 PM the NPO order was canceled; 07/01/22 at 10:00 AM it was documented she was partial assist, patient gets tired quickly and asks to be fed and ate 50 percent oral intake was 240 cubic centimeters (cc); 1:00 PM partial assist and daughter is helping to feed Patient #1, ate 30 percent and 420 cc oral; there was no documentation for supper for 07/01/22. On 07/02/22 and 07/03/22 there was no documentation of any meals consumed. On 07/04/22 at 7:09 PM it was documented she was a partial assist and she ate 50 percent. There was no documentation of oral intake for 07/04/22; on 07/05/22 at 10:00 AM she was partial assist and ate 15 percent and oral intake was 150 cc. Patient #1 was discharged to home at 2:42 PM.

Review of the document titled, Guidelines for Advanced Care Units Routines and Documentation, effective 06/30/22, revealed intake and output, intravenous (IV), enteral, and oral intake and output will be documented at least once a shift and as needed. Oral intake includes any meals.

Review of the patient's flow sheet for the PureWick external catheter revealed the external catheter was started on 07/02/22 at 8:20 PM. The external catheter was not changed until 07/03/22 at 6:49 AM. The manufacturer's guidelines included changing the PureWick catheter every eight to 12 hours and to check the placement and assess the skin every two hours.

There was no documentation the patient's skin was assessed every two hours in accordance with the manufacturer's guidelines.

Review of the medical record for Patient #1 revealed she had an alternating pressure mattress. The initial skin assessment dated 06/27/22 at 11:57 PM revealed turn and reposition, elevate head of bed 30 degrees; encourage activity; offload heels for pressure relief; friction and sheer precautions; specialty bed; and pressure reduction devices.

Review of the turning schedule for Patient #1 revealed she was not turned and repositioned every two hours as follows:
-On 06/27/22 at 11:57 PM revealed a Braden score of 16 and there was no documentation what position Patient #1 was lying.
-06/28/22 at 5:06 AM revealed a Braden score of 16 and no lying position documented; 8:23 AM revealed a Braden score of 18 and supine; 10:25 AM she was on her right side; 10:51 AM she was on her left side; 4:28 PM revealed a Braden score 18 and supine; 8:54 PM revealed a Braden score of 18 lying supine. There was no further documentation for 06/28/22.
-06/29/22 at 2:44 AM she was on her right side; 4:45 AM revealed a Braden score of 18 and lying on her left side; 5:30 AM she was on her right side; 6:22 AM she was on her right side; 6:55 AM she was on her right side; at 9:17 AM revealed a Braden score of 18 and she was supine; at 4:05 PM revealed a Braden score of 15, and the patient was supine in bed; at 8:20 PM she was on her left side; at 10:56 PM she was on her left side.
-On 06/30/22 at 12:49 AM she was on her left side and the Braden score continued to be 15; at 2:26 AM she was on her left side; at 3:59 AM her Braden score was documented as 16; 4:31 AM she was on her left side; at 7:27 AM she was on her right side and the intervention was turn and reposition; at 4:42 PM the Braden score was 16 and the intervention was turn and reposition, there was no documentation of her position; at 7:36 PM she was on her left side. There was no further documentation for 06/30/22.
-On 07/01/22 at 12:31 PM the Braden score continues to be a 16 and she was on her right side; at 6:25 AM she was on her left side; at 9:14 AM she was on her left side; at 4:44 PM she was on her left side; at 8:20 PM she was on her left side. There was no further documentation for 07/01/22.
-On 07/02/22 at 7:53 AM the Braden score continues to be a 16 and she was documented as independent, but did not specify her position; at 7:55 PM it was documented she was independent but did not specify the lying position; at 10:15 PM she was on her left side; at 11:07 PM she was on her right side.
-On 07/03/22 at 2:33 AM the Braden score was 16 and she was on her left side; at 4:28 AM she was on her right side; at 6:47 AM she was on her left side; at 7:45 PM the Braden score was documented as 16 and she was on her left side; at 7:55 PM she was on her right side; at 10:08 PM she was on her left side; at 11:00 PM she was supine;
-07/04/22 at 2:56 AM the Braden score was 16 and she was supine; at 3:33 AM she was on her left side; at 6:07 AM she was on her right side; at 7:59 AM she was on her left side; at 5:15 PM she was on her left side with Braden score of 16; at 7:51 PM she was supine. There was no further documentation for 07/04/22.
-On 07/05/22 at 1:05 AM the Braden score was 16 and she was on her left side; at 3:54 AM she was supine; at 6:23 AM she was on her right side; at 7:45 AM she was on her left side; at 8:15 AM the Braden score continues to be a 16 and there was no position documented; at 10:42 AM she was on her right side; at 12:42 PM the Braden score was 15 and she was on her left side. Patient #1 was discharged from the hospital at 2:42 PM.

Interview with Staff B on 08/17/22 at 9:46 AM revealed a nurse or a patient care technician could document the meal intake and that nursing staff were responsible for removing the patient trays and documenting their intake.

Interview with Staff P on 08/17/22 at 10:11 AM revealed the Braden score for skin was completed one time a shift and as the condition warranted. If the Braden score was less than 18, the patient would require turning and repositioning every two hours.

An interview with Staff T on 08/17/22 at 3:46 PM revealed if a meal was ordered for a patient, then documentation of a meal intake was expected and if a patient's physician orders specify the recording of intakes and outputs the staff were expected to document the meal intake. In addition, she clarified that if a patient was assessed to require staff assistance with eating the intake should be documented.

Interview with Staff B on 08/17/22 at 2:08 PM confirmed confirmed the dressing to an IV site should be changed every Wednesday and as needed and the dressing for Patient #1's site was not changed.

Interview with Staff C on 08/22/22 at 3:25 PM revealed Patient #1 was a moderate assist with meals at times and then minimal assist at times.

Interview with Staff R on 08/22/22 at 3:44 PM revealed the two cardiac strips in the patient's medical record were the only two she could find.

Interview with Staff P on 08/23/22 at 10:46 AM confirmed Patient #1's skin was not assessed every two hours for the Ureic external catheter.

2. Review of the medical record for Patient #3 revealed diagnoses including high blood pressure and hyperglycemia with an insulin drip. Review of physician orders revealed an order for diet as tolerated after discontinuation of the insulin drip, which was stopped on 08/14/22 at 6:44 PM, and a diet order of diabetic diet was noted at 7:33 PM. Review of the meals on the patient daily activity flow sheet for 08/15/22 and 08/16/22 revealed the patient intake was not documented.

Interview with Staff O on 08/17/22 at 3:35 PM confirmed that meals were not documented for Patient #3.

3. Review of the medical record for Patient #4 revealed diagnoses including chronic respiratory failure, obesity, chronic pain, diabetes, and spina bifida.

Interview with Staff O on 08/17/22 at 9:43 AM revealed Patient #4 was assessed to require staff assistance with meal set up and could feed herself once assisted with the tray.

Review of Patient #4's daily activity flow sheet revealed no breakfast, and no dinner intake amounts were documented on the dates 08/10/22, 08/11/22, 08/12/22, and no dinner intake amounts were documented on 08/13/22, 08/14/22 and 08/15/22.

4. Review of the medical record for Patient #5 revealed diagnoses including a bowel obstruction, Parkinson's dementia, high blood pressure, and a history of a subdural hematoma. Review of a functional assessment revealed Patient #5 required one to one assistance of staff for eating, he needed to be fed.

Review of a diet order dated 08/10/22 at 2:10 PM revealed a soft diet was planned after a nasogastric tube was discontinued that date.

Review of a speech therapy evaluation dated 08/13/22 revealed a soft diet was recommended due to the assessment of severe oropharyngeal dysphasia and on 08/15/22 his diet was changed to a level one solids and pudding thick liquids.

Review of the patient's daily activity flow sheet revealed no meal intake documentation for 08/10/22, post-nasogastric tube. Further review of daily flow sheet meal intakes revealed no documentation for breakfast or dinner on 08/11/22, no lunch intake was documented on 08/14/22 and 08/15/22, and no breakfast intake was documented on 08/16/22.

The missing meal documentation in the electronic health record was confirmed by Staff N on 08/16/22 during record review.

5. Review of Patient #6's medical record revealed diagnoses including high blood pressure, pancreatitis, acute respiratory failure and acute kidney injury and review of an activity assessment revealed Patient #6 was assessed to be independent, able to feed himself. Review of physician orders dated 08/11/22 revealed the intake and output for Patient #6 was to be recorded every eight hours with a diet order of clear liquids dated 08/09/22.

Review of the daily flow sheet revealed no meals were documented for 08/15/22, though the patient was off the unit for testing at 6:30 AM and again from 1:51 PM to 3:30 PM, and no meals were documented on 08/16/22. Review of the output flow record revealed no output volume was documented on 08/16/22, or on 08/17/22.

These record review details were confirmed with Staff O on 08/17/22 at 10:18 AM and 10:31 AM during electronic health record review. Staff O verified the order for recording patient intakes and output amounts was still in effect

6. Review of Patient #8's medical record revealed diagnoses included a motor vehicle crash with vertebral fracture and shoulder dislocation, surgical repair and trauma unit management. Review of the physician orders dated 08/05/22 revealed strict intakes and outputs were to be monitored due in part to Patient #8's diagnosis of urinary retention. Further review of physician orders dated 08/07/22 revealed a regular diet began with dinner that date.

Review of the daily flow sheets revealed meal intakes were not recorded on 08/09/22 for dinner, 08/10/22 for lunch, 08/11/22 for breakfast, or dinner, 08/14/22 for lunch, and on 08/15/22, 08/16/22 and 08/17/22 no meal documentation for any meal.

Interview with Staff O on 08/17/22 at 12:08 PM confirmed the missing meal documentation, confirmed that Patient #8 was not off the unit during those mealtimes, that the intake and output tracking order was still in effect, and that the regular diet order was still active.

7. Review of Patient #9's medical record revealed diagnoses included a liver mass, diabetes, and obesity. Review of physician orders dated 08/10/22 revealed a clear liquid diet was ordered at 6:00 PM and intake and output tracking were ordered at 7:00 PM.

Review of Patient #9's daily flow sheets revealed meal documentation was missing on 08/11/22, 08/13/22 and 08/15/22 for all meals, on 08/12/22 and 08/16/22 no lunch or dinner intake documentation.

8. Review of Patient #13's medical record revealed diagnoses included coronary artery disease, dementia and fall with subarachnoid hemorrhage. Review of a nursing assessment revealed Patient #13 required moderate assistance with activities and a physician order for a regular diet.

Review of the daily flow sheet for patient intakes revealed missed documentation for dinner meals on 08/03/22 and 08/04/22 and no meals documented on 08/05/22.

Interview with Staff Y on 08/22/22 at 2:27 PM confirmed the missing meal intake documentation.

This citation substantiates Substantial Allegation OH00133914.

Based on observation and interview, the facility failed to ensure the infection control program includes maintaining a clean and sanitary environment for one patient (Patient #5). The hospital census was 542.

Findings include:

Observation of Patient #5's room on 08/15/22 at 10:30 AM revealed the patient was supine in bed with his eyes were closed. Observation was made of two open containers of applesauce on a shelf in the patient's room. The foiled lids were pulled back exposing the applesause and both containers were approximately half full. There was no date or time on the container as to when the applesause was opened. The nurse manager revealed the applesauce was probably used to adminster the patient's medication and should have been thrown away.

Interview with Staff M on 08/16/22 at 1:04 PM revealed applesauce was only good for four hours after it was opened.

Interview with Staff C on 08/30/22 at 12:23 PM revealed the dietary manager was referring to the state uniform food code rule in regard to applesauce being good four hours after it was opened and that there was no specific hospital policy that addressed this.

This finding substantiates Substantial Allegation OH00133914.