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Based on review of records and interviews, the facility failed to develop and keep current nursing care plans to address the patients' needs for 11 of 11 patients (Patient # 's 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) from 6/13/10 - 9/1/10 in the ICU and on 6-South.

Findings:

Record review of a Park Plaza policy entitled " Admission Assessment and Re-Assessment, " (revision date 1/10) revealed all patients shall be assessed by an RN on admission to the hospital and shall be reassessed by an RN at least daily. The RN assessment shall determine the initial problem list, which is documented on the Care Plan form. The policy further stated " Based on all aspects of the data collection during the initial assessment, the RN is responsible to evaluate and integrate the information collected, including the physician ' s orders and the history and physical. " The policy also stated that each problem will have common interventions to be checked and measurable goals.

Record review of the Park Plaza " Plan of Care " (dated 6/2/10) revealed the Plan of Care is to be reviewed " daily and/or with change in patient condition. "

Record review of patient # 1 revealed the patient was admitted on 6/13/10 with the diagnoses of Diverticulitis, psychosis, and septic shock. The patient was taken to surgery on 6/15/10 for a colostomy. The Plan of Care was implemented on 6/13/10 and included comfort-pain, fluid balance/electrolyte balance, and skin integrity evaluation. On 6/14/10, impaired breathing was added to the care plan. No other problems were identified on the plan of care during this admission.

Record review of patient # 2, Room 212 ICU revealed the patient was admitted on 8/26/10 at 7:42 PM with diagnoses of Urinary Tract Infection (UTI), Altered Mental Status (AMS), bilateral pleural effusion, pulmonary edema, anemia, hypoxemia, malnutrition, and Stage III decubitus. The patient had a score of " 10 " on the Fall Risk Screen which indicated that fall precautions were needed. The Plan of Care was initiated on 8/27/10 and included a plan for the alteration in air exchange, alteration in comfort, alteration in fluid and electrolyte imbalance, and a plan for alteration in skin integrity was added on 8/28/10. No plan was implemented to include the potential for falls, potential for infection, or malnutrition. There were three wound photos but no date or time on them.

Record review of patient # 3 Room 213 ICU, revealed the patient was admitted on 8/30/10 with diagnoses of gastrointestinal bleed, end-stage renal disease, hyperkalemia, and dyspnea. The patient was receiving hemodialysis, received blood transfusions, had blood glucose monitoring ordered for every 6 hours, was on a clear liquid diet, and his Fall Risk Screen indicated he was at risk for falls. The Plan of Care was initiated on 8/30/10 and consisted of plans for alteration in air exchange and alteration in fluid/electrolyte imbalance. In an interview on 9/1/10 at 12:55 PM, RN Manager ICU (staff # 58) stated interventions had been implemented for fall precautions but acknowledged the problem was not addressed on the Plan of Care.

Record review of patient # 4, Room 621, revealed the patient was admitted 8/25/10 with the diagnoses of wound infection with wound dehiscence and recent multiple left toe amputations. The Plan of Care was initiated on 8/26/10 and included Alteration in Comfort, Potential for Infection, and Alteration in Skin Integrity. On 8/28/10, the plan included Psychosocial, cultural, and spiritual needs related to anxiety. On 8/26/10 at 02:22 AM, an entry by Staff # 59 in the nurses ' notes stated " Patient stated she eats what she wants, does not follow prescribed diet. " Education screen listed learning needs as " Diabetes, nutrition, pain management, and smoke cessation. " The Plan of Care did not reflect these problems.

Record review of patient # 5, Room 627, revealed the patient was admitted on 8/29/10 with the diagnoses of new onset atrial fibrillation, bronchitis, and Diabetes Mellitus Type I. Physician orders written on 8/29/10 included an 1800 calorie American Diabetic Association and 2 gram Sodium diet, sliding scale insulin, strict monitoring of the patient ' s intake and output, and daily weights. The Plan of Care was initiated on 8/29/10 and consisted of plans related to alteration in air exchange, alteration in fluid/electrolyte imbalance, and alteration in Glycemic Control. The patient ' s Fall Risk Screen indicated the patient was at increased risk for falls but no interventions were implemented.

Record review of patient # 6, Room 605 revealed the patient was admitted on 8/24/10 with the diagnosis of colon cancer. The Plan of Care was implemented on 8/31/10 and consisted of plans to address alteration in comfort related to surgery, potential for infection related to incision, alteration in nutrition status related to loss of appetite, and alteration in skin integrity related to surgical incision. Physician ' s orders included nothing by mouth then soft diet, blood glucose monitoring and sliding scale insulin, blood transfusions, measurements of all urine output every 8 hours, a bladder scan every 8 hours and if amount is greater than 200 cc to insert a catheter.
In an interview on 9/1/10 at 3:00 PM Clinical Manager of 6-South (staff # 55) stated the patient was admitted on 8/24/10 for surgery and was taken to Room 923 after surgery, then was moved to the Intensive Care Unit on 8/25. On 8/31, the patient was moved to 6-South and the Plan of Care was implemented at that time. Staff # 55 acknowledged the Plan of Care was not initiated on admission also stated the patient ' s problems related to elimination and diabetes should have been included in the care plan.

Record review of patient # 7 revealed the patient was on a ventilator via tracheostomy collar. She had abdominal surgery and a new colostomy on 8/29/10. The plan of care included surgery, colostomy, and airway but interventions specific to the patient were not documented.

Record review of patient # 8 revealed the patient was admitted 8/29/10 with a diagnosis of acute appendicitis. He had surgery on 8/29/10. This patient had documentation of fall precautions on his initial assessment; this was not reflected in his plan of care.

Record review of patient # 9 revealed the patient was admitted 8/27/10 for an infected right hip wound. He had surgery on 8/30/10 to debride the wound. The patient had invasive lines, a poor appetite, was on an 1800 calorie diet. All problems were included in the plan of care except for the nutrition needs.

Record review of patient # 10 revealed the patient was admitted 8/30/10. Some of the patient ' s problems included were dehydration, fair appetite, and a special 4 gram sodium pureed diet. The patient had a 48-hour calorie count that ended on 8/31/10 and there was documentation in the progress notes of " add boost pudding 1 can three times a day " by the Dietician. The care plan for this patient did not reflect the nutrition problem and the boost pudding had not been initiated.

Record review of patient # 11 revealed the patient was admitted 8/19/10 with multiple medical problems. The patient was on oxygen supplement, on sliding scale insulin, receiving scheduled insulin, and on formula feeding via peg tube. There was no plan of care for this patient ' s nutritional needs, nor was there mention of blood sugar checks.