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Based on interview, and record review, the facility failed to develop and implement an individualized, goal directed, plan of care for patients when;

1. One out of 21 sampled patients (Patient 10), who received multiple pain medications, did not have a care plan for pain.

2. One out of 21 sampled patients (Patient 21), who had multiple surgeries, and was on multiple antibiotics had no care plan for infection.

3. One out of 21 sampled patient (Patient 1), who received medication for pain and fever, did not have a care plan for pain or fever.

These failures had the potential for patients not receiving individualized patient care to address their needs.

Findings:

1. A review of Patient 10's face sheet (a document that provided the demographic data of the patient) indicated that a 82 year old female was admitted to the facility on July 1, 2018, with diagnosis of gastro intestinal bleeding (G I bleeding- bleeding occurs in your esophagus, stomach, or initial part of the small intestine).

A review of Patient 10's Medication Administration Record (MAR) indicated that Patient 10, received pain medicine as follows:

a) Injection Morphine 2milligram (mg-a unit of measurement) on July 2, 2018, at 2:41 AM, for pain level of 6 (six) out of 10 (a pain measurement tool with a scale of 10, and 10 being the severe pain).

b) Tablet Norco (Acetaminophen-HYDROcodone 325/5 ) two tablets on July 3, 2018, at 9:25 PM.

The record review of Patient 10's care plan was conducted with Clinical Quality Coordinator Registered Nurse (CQCRN) on July 5, 2018, at 9:25 AM. The CQCRN stated that Patient 10 had no care plan for pain initiated. She further stated that a patient who received a pain medication should have a care plan for pain.

During an interview and concurrent record review with the Clinical Quality Coordinator Registered Nurse (CQC RN), on July 3, 2018 at 3:03 PM, the CQC RN stated that Acetaminophen was administered on the dates indicated and that there was no documented evidence that care plan was initiated for fever or pain.

During review of the facility's policy and procedure titled, "Care of Patient, Critical Care Standards," it dated June 2016, it indicated, " ...2. Patient Plan of Care 2.1 Every patient will have an individualized plan of care that reflects the patient's care needs. The nurse will ensure that the patient's plan of care is individualized, goal directed and reflects the patient's current needs."

A review of the facility policy and procedure titled "Documentation; plan of care; multidisciplinary; guidelines for use of" revised on June 2017, indicated. " ...Every patient admitted to the medical center should receive a planned interdisciplinary approach to care after the needs of the patient have been identified. Documentation of the plan of care should be done in the electronic health record (EHR) by the caregivers ...The plan of care located in the EHR and should be activated for all problems identified ..."

2. A record review of Patient 21's face sheet indicated that a 59 year old female admitted to the facility on May 4, 2018, with diagnosis of perforated viscus (a hole in the wall of part of the gastrointestinal tract.) (GI tract- is an organ system responsible for consuming and digesting foodstuffs, absorbing nutrients, and expelling waste).

A review of Patient 21's clinical record indicated Patient 21 had 9 (nine) surgeries from May 4, 2018 through June 14, 2018.

A review of Patient 21's Physician orders and MAR from May 4, 2018 through July 5, 2018, indicated that Patient 21 received multiple doses of antibiotics for prevention and management of bacterial infection as follows:

a. Injection Piperacillin-tazobactam (Zosyn- a medication that used to treat bacterial and parasite infections) from May 4 through May 12, 2018.

b. Injection Vancomycin (another medication that used to treat bacterial and parasite infections) from May 15 through May 31, 2018.

A concurrent interview with the Clinical Quality Coordinator Registered Nurse (CQC RN), and record review, the RN stated that Patient 21 had no documented evidence of a care plan on infection (potential or actual).

During an interview with RN 3, on July 5, 2018, at 10:32 AM, he stated that a patient who had surgery and received antibiotic should have a care plan on potential /actual infection.

During an interview and concurrent record review with the CQC RN, on July 3, 2018 at 3:03 PM, the CQC RN stated that Acetaminophen was administered on the dates indicated and that there was no documented evidence that care plan was initiated for fever or pain.

During review of the facility's policy and procedure titled, "Care of Patient, Critical Care Standards," it dated June 2016, it indicated, " ...2. Patient Plan of Care 2.1 Every patient will have an individualized plan of care that reflects the patient's care needs. The nurse will ensure that the patient's plan of care is individualized, goal directed and reflects the patient's current needs."

A review of the facility policy and procedure titled "Documentation; plan of care; multidisciplinary; guidelines for use of" revised on June 2017, indicated. " ...Every patient admitted to the medical center should receive a planned interdisciplinary approach to care after the needs of the patient have been identified. Documentation of the plan of care should be done in the electronic health record (EHR) by the caregivers ...The plan of care located in the EHR and should be activated for all problems identified ..."



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3. A review of Patient 3's face sheet indicated that he was admitted to the facility on June 19, 2018, with the diagnosis of chronic respiratory failure (inability to breath normally).

During review of the physicians order dated July 1, 2018, indicated an order for acetaminophen (pain reliever) 325 mg (milligram - unit of measurement) tab (tablet) 650 mg 2 tab, PO (by mouth) every 4 hours.

During review of medication administration record, it indicated that acetaminophen 650 mg was administered on:

a. June 20, 2018 at 9:32 AM for temperature of 39.9 degrees centigrade (unit of measurement).

b. June 27, 2018 at 3:24 PM (No indication why medication was administered).

c. June 29, 2018 at 9:25 PM for temperature of 37.5 degrees centigrade.

d. July 2, 2018 at 9:30 PM for pain.

During an interview and concurrent record review with the Clinical Quality Coordinator Registered Nurse (CQC RN), on July 3, 2018 at 3:03 PM, the CQC RN stated that Acetaminophen was administered on the above mentioned dates, that there was no documented evidence that the care plan was initiated for fever or pain.

During review of the facility's policy and procedure titled, "Care of Patient, Critical Care Standards," it dated June 2016, it indicated, " ...2. Patient Plan of Care 2.1 Every patient will have an individualized plan of care that reflects the patient's care needs. The nurse will ensure that the patient's plan of care is individualized, goal directed and reflects the patient's current needs."

A review of the facility policy and procedure titled "Documentation; plan of care; multidisciplinary; guidelines for use of" revised on June 2017, indicated. " ...Every patient admitted to the medical center should receive a planned interdisciplinary approach to care after the needs of the patient have been identified. Documentation of the plan of care should be done in the electronic health record (EHR) by the caregivers ...The plan of care located in the EHR and should be activated for all problems identified ..."