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Based on observation, interview, record review and facility policy review, facility staff failed to develop a comprehensive nursing plan of care that was updated timely to ensure patient's care needs were met and response to interventions were assessed for sixteen (#18, #36, #38, #1, #2, #3, #4, #5, #6, #7, #8, #12, #13, #57, #58 and #59) of 23 current patients sampled and seven (#14, #15, #16, #17, #18, #19 and #20) of seven discharged patient medical charts sampled. The facility also failed to include discharge planning in the plan of care for all patients in the facility. Failure to have an accurate interdisciplinary plan of care has the ability to affect all patients in the facility. The facility census was 342.

Findings included:

1. Record review of the facility's policy titled, "Plan of Care", dated 10/13/09, showed the following direction:
- The Registered Nurse (RN) will facilitate an interdisciplinary, collaborative approach as the patient's plan of care is managed.
- The initial patient assessment on all inpatient admissions must be completed within the first 24 hours of the admission.
- The patient will be reassessed at a minimum, every eight hours or more often based on patient condition or upon physician order.
- Documentation of the nursing diagnoses/problems will be recorded by the registered nurse on the Nursing Plan of Care at the time of admission and when a new diagnosis/problem is identified.
- The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.
- The registered nurse implements the identified plan.
- The evaluation will be documented at least every 24 hours on the Daily Evaluation section of the Nursing Plan of Care.

2. . Record review of the facility's policy titled, "Documentation of Clinical Services - Social Services", revised on 03/28/2007, showed the following direction:
Policy: The purpose of Social Services documentation in the medical record is to establish initial assessment information to provide continuing follow-up/reassessment information and to provide plan of care and treatment information for each patient open to Social Services.

- Initial assessment documentation includes information about the patient's social, psychological and functional status, family/social support, living situation, current services and equipment in the home, and, as appropriate, the plan for transfer or discharge.
- Social Services documentation adheres to the NASW [National Association of Social Workers] standards of Social Work Practice in Health Care Settings that are as follows:
- Comprehensive assessment and services delivered to the patient, including the development of a plan of care;
- Ongoing assessments, interventions and treatment planning;
- Goals and planning;
- Documentation of outcomes;
- Social Services documentation must comply with hospital, state, and regulatory requirements as outlined on the form used for documentation monitoring.

3. Observation on 08/09/11 at 10:30 AM showed Patient #18 in bed, crying.

Review on 08/09/11 of current Patient #18's medical record showed he/she was admitted on 07/28/11 for a massive left pleural effusion (fluid in the lung). The patient also had a history of depression and had recently been diagnosed with lung cancer. The plan of care did not address the patient's depression or using the incentive spirometer (tool used for deep breathing exercise) to assist with respiratory status. The plan of care had not been reviewed since 08/07/11, two days since last reviewed.

During an interview on 08/09/11 at 1:50 PM, Staff NN, RN (Registered Nurse), stated that he/she was Patient #18's nurse and stated that the patient was on Celexa for the depression.

During an interview on 08/09/11 at approximately 2:00 PM, Staff LL, RN, Director of Medical Step-Down Unit, stated that Patient #18 should have had depression included in the plan of care. Staff LL stated that the depression and incentive spirometer were not included in the plan of care.

4. Review of current Patient #36's medical record showed he/she was admitted on 08/01/11 for a perforated appendix. The plan of care had not been started until 08/08/11, seven days after admission.

During an interview on 08/09/11 at approximately 3:15 PM, Staff LL stated that Patient #36's plan of care was not done in ICU.

5. Review of current Patient #38's medical record showed he/she was admitted on 08/02/11 for chronic airway obstruction. The patient's plan of care was not reviewed on 08/05/11, 08/06/11, or 08/07/11.

During an interview on 08/10/11 at approximately 10:00 AM, Staff LL stated that Patient #38's plan of care was not updated on 08/05/11, 08/06/11, or 08/07/11.

6. During an interview on 08/09/11 at approximately 2:00 PM, Staff LL, RN, stated that the plan of care was supposed to be updated at least every 24 hours.


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7. Record review of the care plans in the current medical records for Patients #1, #2, #3, #4, #5, #6, #7, #8, #12, #13, #57, #58 and #59 showed no discharge planning documentation.

8. Record review of the care plans in the discharged patients' medical records for Patients
#14, #15, #16, #17, #18, #19 and #20 showed no discharge planning in the documentation.

9. During an interview on 08/10/11 at 10:00 AM, Staff UU, Master's in Social Work (MSW), Lead patient Resource Manager, stated that Discharge Planning is not part of the plan of care and that resource people do not enter documentation on the [patient] care plan. He/she also stated the care plan is not interdisciplinary because it does not include social services documentation for patient resource notes or patient updates.

Based on observation, interview, record review and policy review the facility failed to administer medication within the required time frames of 30 minutes prior until 30 minutes after the specified administration time for three (#25, #12 and #13) of three patients observed. When medications are not administered within research based guidelines as ordered by a physician it can be potentially harmful or fail to achieve the desired treatment affect for the patient. The facility census was 342.

Findings included:

Record review of the facility's policy titled, "Medications: Errors and Adverse Reactions" dated 04/01/09 showed direction that a medication error involves the following incidents: Wrong time (>1 hour before or after scheduled dose). (Which does not meet the requirement of 30 minutes prior and 30 minutes after the scheduled dose.)

1. Observation on 08/10/11 at 9:50 AM showed Staff AA, Registered Nurse (RN) administering the following medications:
-Lovenox (medication for blood thinning) Injection 120 milligrams (mg) Subcutaneous (sub q).
-Lasix 40 mg Intravenous push (IVP) 4 ml (milliliters)
These medications were scheduled for 9:00 AM.

-Baby Aspirin 81 mg po (by mouth).
This medication was scheduled for 8:00 AM.

2. During an interview on 08/09/11 at 1:30 PM, Staff W, RN stated that medications can be given one hour after the scheduled time before it is considered late.

3. During an interview on 08/09/11 at 2:00 PM, Staff III, RN stated that medication can be given one hour prior to and one hour after the scheduled dose before it is considered given at the wrong time.

4. During an interview on 08/10/11 at 10:30 AM, Staff AA, RN stated that there is a one hour window prior to and after the scheduled medication time to give medications.


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5. During an interview on 08/10/11 at 10:00 AM, Staff GG, Clinical Safety Manager Acute Rehab, stated that the facility computer system gives a nurse one hour before and after the scheduled medication time to give the medication.

6. During an interview on 08/11/11 at 2:26 PM, Staff GGG, RN stated that staff nurses had thirty minutes before and after the scheduled medication time to give the medication and that this was hospital wide.




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7. During an interview on 08/10/11 at approximately 7:45 AM, Staff OO, RN, Clinical Safety Manager on the medical step-down unit, stated that they have one hour before and one hour after the scheduled medication time to deliver the medications.


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8. During an interview on 08/10/11 at 7:20 AM, Staff C, RN, Nurse Manager, stated that there is a two hour window for medication administration - one hour before to one hour after the ordered medication administration time.

9. Observation on 08/10/11 at 8:15 AM showed Staff M, RN, administered the following medications to Patient #12:
- Lisinopril, scheduled for 9:00 AM;
- Lovenox 50 mg injected sub q scheduled for 9:00 AM.

During an interview on 08/10/11 at 8:15 AM, Staff M, RN, stated he/she had one hour before and one hour after the medication ordered time, "if it is an 8:00 AM medication, I can give it from 7:00 AM to 9:00 AM, I'm passing the 9:00 AM meds (medications)".

10. Observation on 08/10/11 at 8:20 AM, Staff M, RN, administered the following medications to Patient #13:
- Lisinopril (used to treat hypertension, congestive heart failure and to improve survival after a heart attack) 5 mg;
- Predisone (used to treat allergic disorders, ulcerative colitis, psoriasis and arthritis) 10 mg;
- Cardizem (used to treat hypertension (high blood pressure), angina (chest pain), and heart rhythm disorders) 180 mg;
- Vitamin B12 (vitamin B12 deficiency, increase your energy, enhance your immunity, promote good mood, and support mental function) 100 mg . This medication was scheduled at 9:00 AM.
- Lovenox 4 ml injected sub q (just under the skin);
- Prinivil (used to treat elevated blood pressure and heart failure) 20 mg.
These medications were scheduled to be administered at 9:00 AM.