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Based on staff interview and review of medical records and policies, it was determined the hospital failed to ensure a nursing care plan was developed on admission and addressed the nursing needs of 5 of 5 patients (#1, #2, #4, #5 and #6) whose treatment plans were reviewed. This resulted in a lack of direction for nursing staff. Findings include:

1. Patient #4 was a 59 year old female admitted on 4/19/12, for suicidal ideation and depression. A medical "History and Physical Examination" was completed by the physician on 4/19/12. The physician documented Patient #4 had chronic restrictive versus obstructive lung disease and chronic back pain. The physician ordered medications to treat the conditions.

On 4/19/12 at 4:50 PM, the physician ordered Oxygen 1-2 lpm to be used to keep her Oxygen saturation levels above 90%. The Oxygen was to be used at night and as needed during the day and her Oxygen saturation levels were to be checked and documented each shift to indicate how much Oxygen she was using at the time of the assessment. The following day, 4/20/12 at 4:51 PM, the physician ordered CPAP with warm humidification. On 4/30/12 at 1:10 PM, a physician order indicated that Patient #4 would be able to receive a less restrictive level of observation provided she was adherent to her Oxygen order for 24 hours.

Nursing notes indicated Patient #4 was occasionally noncompliant with her use of supplemental oxygen and would experience decreased Oxygen saturation levels. For example, on 4/26/12 at 8:09 PM, the RN documented that Patient #4 presented to the front desk complaining of shortness of breath with an Oxygen saturation level of 84% on room air. The RN documented that Patient #4 told him she did not want to wear her Oxygen. On 5/14/12 at 6:38 PM, the RN documented Patient #4 "was observed without her supplemental O2 [Oxygen] again this shift. She had been non-compliant earlier as she ambulated the halls following a clinic appt [appointment] that did not meet pt [patient] expectations r/t [related to] her care." The Physical Therapist working with Patient #4 documented in a progress note, on 5/12/12 at 2:18 PM, that "pt mentioned getting busted not having [sic] her O2 on and [physician name] saw her."

Patient #4's medical record contained a "MASTER TREATMENT PLAN" completed by multiple disciplines including physicians, nursing staff, the clinician, and pharmacy staff on 5/02/12, 13 days after Patient #4's admission. According to the documentation on the treatment plan, the next "Review Date" was 5/30/12. The treatment plan addressed Patient #4's depression, her danger to herself, chronic pain, and COPD. Each section addressed contained a description of the problem, long-term and short-term goals, and treatment interventions.

The section related to Patient #4's chronic pain indicated she experienced "chronic pain at times in her back and legs. She is moderately adherent to her medical care." Only one treatment modality was listed, "Medications as prescribed for treatment of chronic pain." The plan did not address non-pharmacological measures that were currently being used to assist Patient #4 in managing her pain such as heat/ice, distraction, or physical therapy exercises.

The section related to Patient #4's COPD indicated she "currently requires the use of supplemental oxygen and a CPAP at night. She is moderately adherent to medial care." Two treatment interventions were listed, patient education related to the understanding of the treatment for COPD and testing as ordered by the physician for diagnosis and treatment of COPD. Treatment interventions did not address how much oxygen was to be used, physical therapy's role in providing education on proper breathing techniques, medication management for her respiratory needs, the use of CPAP with oxygen supplementation at night, and the required oxygen saturation monitoring.

The DON and the Nurse Manager for Patient #4's unit on 5/24/12 were interviewed on 5/24/12 at 3:47 PM. The DON confirmed that a "MASTER TREATMENT PLAN" was completed within 14 days of a patient's admission and was based on the admitting physician's initial assessment. He stated that a specific nursing care plan was not generated but nursing needs were incorporated to the "MASTER TREATMENT PLAN." He stated nursing medical interventions, prior to the development of the treatment plan, were found in the "Plan" section of the physician's "History and Physical Examination." The Nurse Manager stated that the facility viewed the nursing assessments and documentation as the nursing care plan which guided staff in providing interventions and monitoring. The DON confirmed the "MASTER TREATMENT PLAN" did not include all interventions related to Patient #4's nursing needs and was not initiated as soon as possible after admission.

A nursing care plan was not thoroughly developed upon Patient #4's admission.



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2. Patient #1 was a 49 year old female admitted on 4/05/11 for panic disorder and depression. A medical "History and Physical Examination" was completed by the physician on 4/05/11. The Physician documented Patient #1 had obstructive sleep apnea. The Physician wrote an order on 4/05/11 at 11:27 PM for Patient #1 to have 1 lpm of Oxygen as needed while sleeping to maintain Oxygen saturation levels above 90%.

The RN completed an assessment on 4/05/11 and documented Patient #1 was being treated for diabetes. In addition, the RN documented a fold of skin on her lower abdomen with a yeast-like rash and included she was placing washcloths in the fold of skin at night.

Patient #1's medical record contained a "MASTER TREATMENT PLAN" completed by multiple disciplines, which included the psychiatrist, physician's assistant, clinical supervisor, nurse manager, recreational therapist, clinician, treatment coordinator, and direct care staff on 4/14/12, nine days after Patient #1's admission. The treatment plan addressed Patient #1's depression, her danger to herself, and sleep apnea. Each section addressed contained a description of the problem, long-term and short-term goals, and treatment interventions. The only intervention related to sleep apnea was to provide education to Patient #1 regarding the treatment of sleep apnea. Patient #1's Oxygen use was not addressed on the treatment plan.

A nursing care plan was not developed upon admission to address nursing interventions for Patient #1's diabetes, sleep apnea, or impaired skin integrity.

In an interview on 5/25/12 at 9:30 AM, the DON reviewed Patient #1's medical record and confirmed a nursing care plan was not developed after the nursing assessment. He stated the "MASTER TREATMENT PLAN" was developed within 14 days of admission and information from the nursing assessment was used to develop a portion of the plan.

A complete and timely nursing care plan was not developed for Patient #1.

3. Patient #2 was a 58 year old male admitted on 6/22/11 for bi-polar disorder and threatening suicide. In addition, a "HISTORY AND PHYSICAL EXAMINATION," completed by a physician assistant on 6/22/11, documented Patient #2 had type 2 diabetes, sleep apnea, COPD, and a history of stroke.

Patient #2's medical record contained a nursing assessment, dated 6/22/11, that included documentation of arthritis pain in his back, knees and feet. Patient #2's pain was assessed on a scale of 1-10, with 10 being the greatest pain level. His pain level at the time of the assessment was 7/10.

Patient #2's medical record contained a "MASTER TREATMENT PLAN" completed by multiple disciplines which included the psychiatrist, physician's assistant, clinical supervisor, nurse manager, recreational therapist, clinician, treatment coordinator, and direct care staff on 7/05/11, 13 days after Patient #2's admission. The treatment plan addressed Patient #2's depression, his danger to himself, and COPD. Each section addressed contained a description of the problem, long-term and short-term goals, and treatment interventions. The only treatment intervention documented for COPD was education regarding understanding COPD.

The treatment plan did not include nursing interventions such as Oxygen therapy for COPD and pain interventions for his arthritis.

In an interview on 5/25/12 at 9:40 AM, the DON reviewed Patient #2's medical record and confirmed a nursing care plan was not developed after the nursing assessment.

A complete and timely nursing care plan was not developed for Patient #2 on admission.



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4. Patient #5 was a 59 year old female admitted on 12/22/11 for Alzheimer's Disease and schizoaffective disorder. A "PHYSICIAN PROGRESS NOTE - MEDICAL CLINIC," dated 2/10/12 at 2:25 PM, documented Patient #5 had pneumonia. On 2/10/12 at 2:18 PM, the physician ordered 1-2 lpm of Oxygen as needed to keep Oxygen saturation levels above 90%. Oxygen saturations levels were also ordered to be checked and documented every shift.

Patient #5's medical record contained additional physician progress notes related to the lung infection. On 3/06/12, the Physician Assistant documented Patient #5 remained on Oxygen. On 3/13/12, the Physician Assistant documented Patient #5 was no longer using Oxygen. A physician order, dated 3/14/12 at 1:18 PM, directed staff to check Patient #5's Oxygen saturation levels every hour while awake and not to use Oxygen if her saturation levels were above 90% on room air.

Additional "PHYSICIAN PROGRESS NOTE - MEDICAL CLINIC" notes, dated 4/03/12, 4/10/12, and 5/01/12, reflected Patient #5's continued treatment for pneumonia, such as nebulizer treatments and follow-up chest X-rays.

Patient #5's medical record contained a "MASTER TREATMENT PLAN" completed by multiple disciplines on 1/10/12, and again on 3/21/12. Forty days had elapsed between the diagnosis of pneumonia and the review of the treatment plan. The treatment plan addressed Patient #5's psychological and cognitive impairment, inadequate treatment involvement, grave disability and dangerousness to self and others, chronic encephalopathy, cachexia, ataxia, anorexia, and spasticity. Each section of the treatment plan contained a description of the problem, long-term and short-term goals, and treatment interventions.

Patient #5's pneumonia, use of Oxygen and nebulizers, and frequent Oxygen saturation level checks were not included on the plan.

The Assistant DON was interviewed on 5/25/12 at 9:30 AM. He reviewed Patient #5's medical records and stated a specific nursing care plan was not generated. He stated nursing needs were incorporated in the "MASTER TREATMENT PLAN," which was completed within 14 days of a patient's admission. He stated nursing medical interventions, prior to the development of the treatment plan, were found in the "Plan" section of the physician's "HISTORY AND PHYSICAL EXAMINATION." The Assistant DON stated the facility used the nursing assessments and progress notes as the nursing care plan to guide staff in providing interventions and monitoring. The Assistant DON stated the "MASTER TREATMENT PLAN" did not include all interventions relevant to Patient #5's nursing needs and was not initiated as soon as possible after admission.

The facility did not ensure a timely nursing care plan was developed and kept current for Patient #5.

5. Patient #6 was a 36 year old female admitted on 5/02/12 for depressive disorder and homicidal ideation. A medical "HISTORY AND PHYSICAL EXAMINATION" was completed by the Physician on 5/02/12 at 1:31 PM. The Physician documented Patient #6 had obstructive sleep apnea. On 5/02/12 at 2:27 PM, the Physician ordered treatments for this condition, including biPAP or, if no biPAP available, 1-2 lpm of Oxygen with the head of bed at a 45 degree angle. The Physician also ordered Oxygen saturation level checks every shift while walking and with sleeping.

Patient #6's medical record contained a "MASTER TREATMENT PLAN" completed by multiple disciplines on 5/15/12, 13 days after Patient #6's admission. The treatment plan addressed Patient #6's depression, dangerousness to self and others, and polysubstance dependence. Each section of the treatment plan contained a description of the problem, long-term and short-term goals, and treatment interventions.

Patient #6's use of biPAP, Oxygen as needed and Oxygen saturation checks while walking and sleeping were not included on the plan.

The Assistant DON was interviewed on 5/25/12 at 9:30 AM. He reviewed Patient #6's medical records and stated a specific nursing care plan was not generated, but nursing needs were incorporated in the "MASTER TREATMENT PLAN," which was completed within 14 days of a patient's admission. He stated nursing medical interventions, prior to the development of the treatment plan, were found in the "Plan" section of the physician's "HISTORY AND PHYSICAL EXAMINATION." The Assistant DON stated the facility used the nursing assessments and progress notes as the nursing care plan to guide staff in providing interventions and monitoring. The Assistant DON stated the "MASTER TREATMENT PLAN" did not include all interventions relevant to Patient #6's nursing needs and was not initiated as soon as possible after admission.

The facility did not ensure a complete and timely nursing care plan was developed for Patient #6.

Based on staff interview and review of medical records and policies, it was determined the hospital failed to ensure a nursing care plan was developed on admission and addressed the nursing needs of 5 of 5 patients (#1, #2, #4, #5 and #6) whose treatment plans were reviewed. This resulted in a lack of direction for nursing staff. Findings include:

1. Patient #4 was a 59 year old female admitted on 4/19/12, for suicidal ideation and depression. A medical "History and Physical Examination" was completed by the physician on 4/19/12. The physician documented Patient #4 had chronic restrictive versus obstructive lung disease and chronic back pain. The physician ordered medications to treat the conditions.

On 4/19/12 at 4:50 PM, the physician ordered Oxygen 1-2 lpm to be used to keep her Oxygen saturation levels above 90%. The Oxygen was to be used at night and as needed during the day and her Oxygen saturation levels were to be checked and documented each shift to indicate how much Oxygen she was using at the time of the assessment. The following day, 4/20/12 at 4:51 PM, the physician ordered CPAP with warm humidification. On 4/30/12 at 1:10 PM, a physician order indicated that Patient #4 would be able to receive a less restrictive level of observation provided she was adherent to her Oxygen order for 24 hours.

Nursing notes indicated Patient #4 was occasionally noncompliant with her use of supplemental oxygen and would experience decreased Oxygen saturation levels. For example, on 4/26/12 at 8:09 PM, the RN documented that Patient #4 presented to the front desk complaining of shortness of breath with an Oxygen saturation level of 84% on room air. The RN documented that Patient #4 told him she did not want to wear her Oxygen. On 5/14/12 at 6:38 PM, the RN documented Patient #4 "was observed without her supplemental O2 [Oxygen] again this shift. She had been non-compliant earlier as she ambulated the halls following a clinic appt [appointment] that did not meet pt [patient] expectations r/t [related to] her care." The Physical Therapist working with Patient #4 documented in a progress note, on 5/12/12 at 2:18 PM, that "pt mentioned getting busted not having [sic] her O2 on and [physician name] saw her."

Patient #4's medical record contained a "MASTER TREATMENT PLAN" completed by multiple disciplines including physicians, nursing staff, the clinician, and pharmacy staff on 5/02/12, 13 days after Patient #4's admission. According to the documentation on the treatment plan, the next "Review Date" was 5/30/12. The treatment plan addressed Patient #4's depression, her danger to herself, chronic pain, and COPD. Each section addressed contained a description of the problem, long-term and short-term goals, and treatment interventions.

The section related to Patient #4's chronic pain indicated she experienced "chronic pain at times in her back and legs. She is moderately adherent to her medical care." Only one treatment modality was listed, "Medications as prescribed for treatment of chronic pain." The plan did not address non-pharmacological measures that were currently being used to assist Patient #4 in managing her pain such as heat/ice, distraction, or physical therapy exercises.

The section related to Patient #4's COPD indicated she "currently requires the use of supplemental oxygen and a CPAP at night. She is moderately adherent to medial care." Two treatment interventions were listed, patient education related to the understanding of the treatment for COPD and testing as ordered by the physician for diagnosis and treatment of COPD. Treatment interventions did not address how much oxygen was to be used, physical therapy's role in providing education on proper breathing techniques, medication management for her respiratory needs, the use of CPAP with oxygen supplementation at night, and the required oxygen saturation monitoring.

The DON and the Nurse Manager for Patient #4's unit on 5/24/12 were interviewed on 5/24/12 at 3:47 PM. The DON confirmed that a "MASTER TREATMENT PLAN" was completed within 14 days of a patient's admission and was based on the admitting physician's initial assessment. He stated that a specific nursing care plan was not generated but nursing needs were incorporated to the "MASTER TREATMENT PLAN." He stated nursing medical interventions, prior to the development of the treatment plan, were found in the "Plan" section of the physician's "History and Physical Examination." The Nurse Manager stated that the facility viewed the nursing assessments and documentation as the nursing care plan which guided staff in providing interventions and monitoring. The DON confirmed the "MASTER TREATMENT PLAN" did not include all interventions related to Patient #4's nursing needs and was not initiated as soon as possible after admission.

A nursing care plan was not thoroughly developed upon Patient #4's admission.



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2. Patient #1 was a 49 year old female admitted on 4/05/11 for panic disorder and depression. A medical "History and Physical Examination" was completed by the physician on 4/05/11. The Physician documented Patient #1 had obstructive sleep apnea. The Physician wrote an order on 4/05/11 at 11:27 PM for Patient #1 to have 1 lpm of Oxygen as needed while sleeping to maintain Oxygen saturation levels above 90%.

The RN completed an assessment on 4/05/11 and documented Patient #1 was being treated for diabetes. In addition, the RN documented a fold of skin on her lower abdomen with a yeast-like rash and included she was placing washcloths in the fold of skin at night.

Patient #1's medical record contained a "MASTER TREATMENT PLAN" completed by multiple disciplines, which included the psychiatrist, physician's assistant, clinical supervisor, nurse manager, recreational therapist, clinician, treatment coordinator, and direct care staff on 4/14/12, nine days after Patient #1's admission. The treatment plan addressed Patient #1's depression, her danger to herself, and sleep apnea. Each section addressed contained a description of the problem, long-term and short-term goals, and treatment interventions. The only intervention related to sleep apnea was to provide education to Patient #1 regarding the treatment of sleep apnea. Patient #1's Oxygen use was not addressed on the treatment plan.

A nursing care plan was not developed upon admission to address nursing interventions for Patient #1's diabetes, sleep apnea, or impaired skin integrity.

In an interview on 5/25/12 at 9:30 AM, the DON reviewed Patient #1's medical record and confirmed a nursing care plan was not developed after the nursing assessment. He stated the "MASTER TREATMENT PLAN" was developed within 14 days of admission and information from the nursing assessment was used to develop a portion of the plan.

A complete and timely nursing care plan was not developed for Patient #1.

3. Patient #2 was a 58 year old male admitted on 6/22/11 for bi-polar disorder and threatening suicide. In addition, a "HISTORY AND PHYSICAL EXAMINATION," completed by a physician assistant on 6/22/11, documented Patient #2 had type 2 diabetes, sleep apnea, COPD, and a history of stroke.

Patient #2's medical record contained a nursing assessment, dated 6/22/11, that included documentation of arthritis pain in his back, knees and feet. Patient #2's pain was assessed on a scale of 1-10, with 10 being the greatest pain level. His pain level at the time of the assessment was 7/10.

Patient #2's medical record contained a "MASTER TREATMENT PLAN" completed by multiple disciplines which included the psychiatrist, physician's assistant, clinical supervisor, nurse manager, recreational therapist, clinician, treatment coordinator, and direct care staff on 7/05/11, 13 days after Patient #2's admission. The treatment plan addressed Patient #2's depression, his danger to himself, and COPD. Each section addressed contained a description of the problem, long-term and short-term goals, and treatment interventions. The only treatment intervention documented for COPD was education regarding understanding COPD.

The treatment plan did not incl