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Based on interview, documentation in 3 of 3 medical records reviewed of patients in the OBC unit (Patients 1, 2, and 3), and review of policies and procedures, it was determined the hospital failed to ensure that the RN supervised and evaluated the patient's nursing care needs in accordance with physician's orders and policies and procedures in the following areas:
* Assistance with bed mobility
* Weight monitoring
* Nasogastric tube assessments

Findings included:

1. Review of the medical record for Patient 2 reflected the patient was admitted on 03/24/2016 at 0509 with diagnoses that included quadriplegia and Stage IV pressure ulcer of sacral region. The patient underwent surgical repair of the pressure ulcer and was discharged on 04/18/2016 at 1705. Refer to the findings identified under Tag A396, CFR 482.23(b)(4), Nursing Care Plan, that reflects the RN failed to ensure appropriate supervision of bed mobility for Patient 2.

2. The policy and procedure titled "Gastrointestinal Care Management of the Adult Inpatient Receiving Enteral Feedings/Medication" dated "Nov 2014" reflected the following:
* "Verify the position of gastric feeding tubes by auscultation or aspiration of gastric contents at least
every 4 hours in patients with continuous infusion...bolus or intermittent feeding medication."
* "Verify...catheter depth and external length agree with EHR documentation."

3. The medical record for Patient 1 was reviewed and reflected the patient was admitted to the hospital on 02/27/2016 at 1847 with diagnoses that included Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis.

The EHR reflected a DHT was in place from 03/01/2016 to 03/14/2016. Review of the LDA assessment flowsheet revealed that the position and depth of the DHT was not documented as assessed every 4 hours as per hospital policy. On 03/01/2016, the space to chart the depth of the tube was blank for each time assessed. On 03/02/2016, the tube was assessed on only two occasions at 0700 and 2300, neither assessment included the depth of the tube. On 03/08/2016 there were no assessments for position or depth of tube from 0700 through 1500. Similar findings were identified on 03/09/2016, 03/10/2016, 03/11/2016, 03/12/2016, and 03/13/2016.

Additionally, physician orders dated 02/27/2016 at 1933 reflected an order for daily weights. There was no documentation in the EHR that the patient's weight was obtained on the following dates: 02/28/2016, 02/29/2016, 03/01/2016, 03/02/2016, 03/04/2016, 03/09/2016, 03/10/2016, 03/11/2016, 03/12/2016.

4. The medical record for Patient 3 reflected the patient was admitted to the hospital on 04/26/2016 at 0911 with diagnoses that included non-healing surgical wound. The patient was discharged on 04/28/2016.

Physician orders reflected an order for daily weights dated 04/26/2016 at 0919. However, there were no weights documented on 04/27/2016 and 04/28/2016.

5. During interviews on 06/21/2016 beginning at 1100, at the time of record review with the OBC ANM he/she confirmed weights were not consistently performed or documented for Patient's 1 & 3. He/she also confirmed the lack of consistent and complete assessment of the DHT for Patient 1.

Based on interview, documentation in 1 of 1 medical record of a patient who sustained fractures while on the OBC unit, (Patient 2), and review of policies and procedures, it was determined the hospital failed to develop and keep current an individualized nursing care plan based on the patient's problems and needs related to positioning and bed mobility.

Findings included:

1. Review of the medical record for Patient 2 reflected the patient was admitted on 03/24/2016 at 0509 with diagnoses that included quadriplegia and Stage IV pressure ulcer of sacral region. The patient underwent surgical repair of the pressure ulcer that involved patient's left gluteal region and was discharged on 04/18/2016 at 1705.

Review of the patient's initial care plan revealed two references of problems and interventions related to positioning and bed mobility for this dependent quadriplegic patient. A problem of "Pressure Ulcer - Risk of" was dated 03/24/2016 and included the following interventions related to mobility: "Position change q2hrs...Reposition in chair hourly...Educate [Patient]/Family regarding frequent position changes...Educate [Patient]Family regarding activity level in bed/chair." A problem of "Fall and Fall injury Prevention" was dated 03/26/2016 and included the intervention "Assist with activity/mobility." However, the interventions were not individualized, clear or complete as they did not specify the type and amount of assistance required.

In addition the initial care plan was not individualized to reflect all actual and potential problems and needs. For example: there was no problem identified for the patient's dependence for mobility secondary to quadriplegia; there was no problem identified for the actual extensive surgical skin alteration secondary to surgical repair of a stage IV pressure ulcer.

A nursing note recorded by an RN on 03/30/2016 at 1057 was identified as a late entry from 03/26/2016 at 1835. The note reflected: "Pt turned q2h per flap protocol. During turning, loud pop heard in [patient's] L. shoulder area. [Patient] denied pain, actually stating it didn't hurt and felt better after popping. Area examined and appeared WNL. Monitoring continues."

There was no documentation in the medical record, including the care plan, that described the "flap protocol" referenced in the nursing note.

An X-ray report recorded by an MD on 03/28/2016 at 2124, reflected: "X-ray Humerus Left...Findings: Oblique slightly comminuted but not significantly displaced fracture of the distal left humerus shaft. No other fractures and no dislocation. Bone density is normal."

There was no evidence of nursing assessment nor evidence that the care plan had been reviewed and modified after the L humerus fracture was identified. No changes to the care plan were documented.

A nursing note recorded by an RN on 04/13/2016 at 1717 reflected: "...overnight on 4/12/16 [patient] experienced a "popping" noise from R arm during turning-RN notified MD and [patient] was evaluated for injury immediately..."

An X-ray report recorded by an MD on 04/13/2016 at 1551 reflected: "X-ray Humerus Right...Impression: Comminuted minimally displaced fracture through the midshaft of the right humerus. Enteric humerus appears grossly demineralized..."

After the R humerus fracture was identified, the only changes to the care plan were the addition of the following two problems: "Upper Extremity" and "Skin Integrity," both dated 04/14/2016. Those problem statements were unclear and incomplete and no interventions were identified under either of the problems.

2. The policy and procedure titled "Interdisciplinary Plan of Care" dated last reviewed "Oct 2014" reflected: "The Registered Nurse will develop an individualized care plan for each patient admitted as an inpatient...The nursing process will be utilized to determine the appropriate problems (nursing diagnoses), interventions and goals for each patient...The Registered Nurse will review the care plan every shift. Problems, interventions and goals will be revised as needed to meet patient care needs...The care plan should be modified through the addition of new problems, goals or interventions..."

3. During an interview on 06/20/2016 at 1125 with the OBC unit NM, he/she acknowledged the lack of modifications to the care plan after the first fracture, and stated "we felt like we were doing everything we could already be doing," He/she also acknowledged the lack of modifications to the care plan after the second fracture and described the "flap protocol" as an internal guideline for the burn unit that is printed and placed in the patient's room. He/she stated it is not part of the permanent medical record.

On 06/21/2016 at 0930, the OBC unit NM indicated that, after the first fracture, the IDT determined the fracture was pathological and that no new interventions were needed to reduce Patient 2's risk for future fractures. He/she confirmed that no interventions were added to the care plan and stated "there was nothing else we could do, we were already doing everything we could do for this patient." He/she also confirmed that a nursing assessment to support the lack of new interventions was not done, and stated, "I couldn't find one."

During an interview on 06/21/2016 at 0930 the OBC unit ANM acknowledged that after the second fracture PT outlined a process to reduce the risk of further injury. He/she stated "it would have been nice to have this note after the first fracture." He/she further confirmed that the process of updates to the care plan "is not something we look at very often."