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Based on clinical record review and staff interview, the hospital failed to update Patient #7's nursing care plan in accordance with physician orders for activity, failed to document nursing interventions needed for safe care as part of Patient #8's nursing care plan, failed to develop a comprehensive nursing care plan for incontinence for Patient #4 and #9, and failed to develop patient specific care plans for eating and call light placement for Patient #9 and #10. In all, Patient #4, #8, #9, and #10 represent four affected patients out of 11 sampled. The census at the time of the survey was 326 patients.

Findings included:

The clinical record review for Patient # 7 was completed on 03/23/11. This patient was admitted to the hospital on 03/17/11 with a diagnosis of uncontrolled diabetes. Physician orders at the time of admission included an activity order of bedrest. This order remained in effect until the physician wrote a new order on 03/21/11 at 11:45 AM for the activity to advance to being up in the chair three times daily. The nursing documentation did not reveal the patient had been up in the chair any time from 03/21/11 at 11:45 AM through the time the record was reviewed on 03/23/11 at 11:40 AM. The nursing documentation did reveal the patient ambulated with a steady gait on 03/22/11 at 7:55 AM. Interview with the patient on 03/23/11 at 11:25 AM revealed, " I had to ask for help to the bathroom when I first came in but now I can go on my own." This statement by the patient was inconsistent with the activity ordered by the physician or the nursing documentation. These findings were confirmed during interview with Staff G while reviewing the clinical record with Staff G on 03/23/11 at 11:40 AM.

The clinical record review for Patient # 8 was completed on 03/23/11. This patient was admitted to the hospital on 11/27/10 after a fall at home and was discharged to an extended care facility on 11/30/10. The plan of care for this patient developed by the registered nurse listed "weakness, left hip" as a problem with a goal of "no falls" while hospitalized. Review of the clinical record did not reveal nursing interventions to be utilized to achieve that goal. Nursing documentation on 11/28/10 at 12:30 PM revealed the patient was walking back from the bathroom using a cane and the assistance of a nurse aide. The patient became limp and unresponsive while walking back to bed. Physician documentation on the discharge summary dated 11/30/10 revealed the event was described as a fall onto her knees. Nursing documentation did not reveal how many personnel had assisted the patient to the bathroom prior to the event, nor how many personnel were recommended in assisting the patient with ambulation. These findings were confirmed with Staff A and B on 03/23/11 at 4:30 PM.



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The clinical record review for Patient #9 was completed on 03/23/11. The clinical record review revealed the 54-year-old patient was admitted to the facility on 12/30/10 with diagnoses of encephalopathy and seizures. The clinical record review revealed a history and physical dated 12/30/10 at 10:15 P.M. that stated that morning he/she was unable to stand and wouldn't answer questions. The history and physical stated his/her significant other took a pulse oximetry reading that showed his/her oxygen saturation was between 70 and 80 percent and emergency medical services was contacted. The history and physical stated the patient had a right frontal craniotomy on November, 2007, and had a post seizure disorder. The history and physical stated the patient was blind in the right eye. The history and physical stated Patient #9 appeared to be sleeping, was alert and oriented times one, and responded to questions inappropriately. The history and physical stated, "? recurrent unwitnessed seizure and/or prolonged post-ictal state ....Observe for seizures."

A review of Patient #9's physician orders was completed on 03/23/11. The review revealed on admission a physician order (dated 12/30/10 at 10:00 P.M.) that stated the patient was placed on bedrest and an order for indwelling urinary catheter.

The clinical record review revealed a nursing flow sheet that stated the patient #9 was incontinent of stool once on 12/31/10.

The clinical record review revealed a microbiology report dated 01/01/11 that stated the patient was positive for C. difficile.

The clinical record review revealed nursing flow sheets that stated the patient was incontinent of stool four times on 01/01/11, incontinent of stool three times on 01/02/11, incontinent of stool two times on 01/03/11 and incontinent of stool two times on 01/05/11.

The clinical record review revealed a physician's order dated 01/03/11 at 1:50 P.M. that stated to remove the indwelling urinary catheter. The clinical record review revealed the patient was both continent and incontinent of urine on 01/05/11 at 1:41 P.M.

In sum, the patient #9 was incontinent of stool 11 times and urine one time.

The review revealed on 01/01/11 at 8:00 A.M. the physician ordered to have the patient's diet advanced as tolerated. On 01/02/11 at 6:00 A.M. Patient #9 ate 25 percent of his/her breakfast and was fed. The clinical record review revealed he/she ate all of his/her dinner.

The review revealed on 01/02/11 at 8:40 A.M. the physician ordered a regular diet. Patient #9 fed himself/herself a regular breakfast on 01/03/11.

The clinical record review revealed he/she took 100 percent of his/her breakfast on 01/04/11 and 85 percent of his/her dinner on 01/06/11. On 01/05/11 the patient fed himself lunch and ate 100 percent of it.

A review of the nursing care plans did not reveal how Patient #9's blindness to the right eye was addressed for call light placement or dietary tray placement. The review did not reveal a care plan that directed the nursing staff on how much assistance Patient #9 needed to eat. The review did not reveal a care plan that addressed how the nursing staff was to manage Patient #9's bowel and urinary incontinence.

On 03/23/11 at 1:45 P.M. in an interview Staff K confirmed there wasn't a care plan to address the patient's call light and tray placement, or one to address how much or how little assistance he/she needed to eat, or one to address bowel and/or bladder incontinence.

A review of the nursing notes revealed they did not state on which side of the patient the call light was placed.

A review Patient #10's clinical record was completed on 03/23/11. The review revealed a trauma history and physical dated 03/19/11 at 9:00 A.M. that stated the patient was an unrestrained driver of a motor vehicle accident. The history and physical stated the patient had a left midshaft radial and ulnar fracture. A review of a physician's consultation dictated on 03/19/11 at 8:11 P.M. stated the patient had a left forearm "both-bone" midshaft fracture.

On 03/22/11 in the afternoon, the surveyor interviewed Staff J regarding Patient #10. Staff J stated Patient #10 needed assistance with eating principally to cut up the food as necessary.

The clinical record review did not reveal a plan of care that directed the nursing staff to ensure placement of the call light on the patient's good side or a plan of care that directed the nursing staff as to how much assistance the patient needed to eat.

On 03/23/11 at 2:47 P.M. in an interview, Staff K confirmed the patient did not have a care plan that addressed the patient's need for assistance in eating or placing the call light on the patient's good side.

The clinical record review for Patient #4 was completed on 03/23/11. The clinical record review revealed the 62-year-old patient was admitted to the facility with a diagnosis of diarrhea. A review of a history and physical dictated on 03/21/11 stated he/she complained of 10 to 15 episodes a day.

On 03/22/11 in an interview, Staff I stated Patient #4 would have stool accidents because he/she wouldn't always make it to the bathroom on time.

On the afternoon of 03/22/11, the surveyor interviewed Patient #4 who denied any complaints regarding hygiene. He/she said he/she has had issues with diarrhea and that the nursing staff brought in a bedside commode to decrease the chance of any incontinence.

The clinical record review did not reveal a nursing care plan that addressed the urgency to stool the Patient #4 experiencing.
On 03/22/11 at 2:20 P.M. in an interview, Staff I confirmed the patient did not have a nursing care plan that addressed the urgency to stool that the patient was having.