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Based on review of clinical records, physician's orders and interview, it was determined a Registered Nurse failed to supervise the care for 6 (#9-#12, #14-#15) of 15 (#1-#15) patients in that care was not rendered per physician's orders and policy and procedure. Failure to provide care per physician orders and per established policy did not ensure patients received the highest quality of care to facilitate the patient's attainment of the highest level of wellness. The failed practice affected 6 (#9-#12, #14-#15) of 15 (#1-#15) patients on 01/28/15. Findings follow:

A. Review of the policy and procedure titled "Patient Assessment & (and) Reassessment Standards" received from the Director of Quality at 0925 on 01/27/15 revealed: ... B. Current Patients: 1. Critical Care Units (E4, F4, H4) viii. Weights are performed and documented daily.

B. Review of Patient #9's clinical record revealed an admission date of 01/16/15 with admission orders that included daily weights, CBG (Capillary Blood Glucose) levels AC and HS (before meals and at hour of sleep) - call physician if below 70, Nitroglycerin 0.4 mg (milligram) Maximum of three doses in 15 minutes, if no relief, contact MD (Medical Doctor). Review of the nursing notes revealed Patient #9 was not weighed from 01/18/15 through 01/23/15; a CBG was performed at 1611 on 01/21/15 with results of 61 and the physician not notified; and three Nitroglycerin were administered on 01/16/15 at 1621, 1629 and 1638 without documentation the physician was notified. During an interview with Instructional Designer #1 at 1550 on 01/27/15 she verified the above findings.

C. Review of Patient #10's clinical record revealed an admission date of 01/25/15 with admission orders that included CBG AC and HS (before meals and hour of sleep). Review of the nursing notes revealed CBG was not performed at supper on 01/26/15. During an interview with Instructional Designer #1 at 0915 on 01/28/15 she verified the above findings.

D. Review of Patient #11's clinical record revealed an admission date of 01/23/15 with admission orders that included daily weights, CBG every six hours and TEDs (thromboembolism-deterrent) hose. Review of the nursing notes revealed Patient #11 was not weighed on 01/26/15 and 01/27/15, CBG was not performed at 2100 on 01/26/15 and the TEDS were still not placed at time of record review. During an interview with Instructional Designer #1 at 0942 on 01/28/15 she verified the above findings.

E. Review of Patient #12's clinical record revealed an admission date of 01/25/15 with admission orders that included daily weights and TEDs with SCDs (sequential compression device). Review of the nursing notes revealed Patient #12 was not weighed on 01/26/15 and TEDs/SCDs were not placed until 2000 on 01/27/15. During an interview with Instructional Designer #1 at 1035 on 01/28/15 she verified the above findings.

F. Review of Patient #14's clinical record revealed an admission date of 01/24/15 to the F4 Unit, with admission orders that included daily weights. Review of the nursing notes revealed Patient #14 was not weighed on 01/25/15, 01/26/15 and 01/27/15. During an interview with Instructional Designer #1 at 1130 on 01/28/15 she verified the above findings.

G. Review of Patient #15's clinical record revealed an admission date of 01/20/15 to the F4 unit, with admission orders that included TEDs/SCDs, and CBGs every six hours. Review of the nursing notes revealed the TEDs were still not placed at time of record review. During interviews with Instructional Designer #1 at 1203 and the Director of Clinical Informatics at 1213 on 01/28/15 the above findings were verified.

Based on clinical record review, policy and procedure review and interview, it was determined the Facility failed to ensure a current and comprehensive nursing care plan was developed based on the patient's needs for 4 (#9, #11, #13 and #15) of 15 (#1-#15) patients. Failure to develop and maintain a current and comprehensive plan of care was likely to affect the nursing care rendered to ensure the patients received optimum care to progress and be discharged. The failed practice affected Patient #9, #11, #13 and #15 on 01/28/15. Findings follow:
A. Review of the policy and procedure titled "RN (registered nurse) Assessment" received from the Director of Compliance and Regulatory at 1130 on 01/28/15 revealed under RN ASSESSMENT, the following:...
"6. The analysis/interpretation of the data collected must be performed by the RN and is the assessment which proved the basis for the development of the nursing plan of care.
7. Each patient's nursing plan of care may consist of pre-determined hospital approved standards of care/practice appropriate to the patient or be developed as an individualized action plan.
8. Assessment data from the comprehensive nursing assessment and ongoing periodic reassessments of the patient by RNs will be incorporated into the interdisciplinary care planning process through the unit based interdisciplinary care meetings.
9. A plan of care will be instituted within 24 hours of admission ...".

B. Review of the clinical record of Patient #9 revealed an admission date of 01/16/15 with admission diagnoses which included Irritable Bowel Syndrome, Schizophrenia, Overdose, Diabetes Mellitus (DM), Cocaine Dependence, Polysubstance Abuse, Iron Deficiency Anemia, Nausea and Vomiting, Abdominal Pain, Chest Pain, Hypertension (HTN), Gastroesophageal Reflux Disease (GERD), Esophageal Thickening and Gastritis. Review of the Multi-disciplinary Problems (facility nursing care plan) revealed no nursing care plan developed for the care related to any of the admitting diagnoses. During an interview with Instructional Designer #1 at 1530 on 01/27/15 the above findings were verified.

C. Review of the clinical record of Patient #11 revealed an admission date of 01/23/15 with admission diagnoses which included Congestive Heart Failure (CHF), HTN, DM, AKI (acute kidney injury), Iron Deficiency Anemia, Acute Renal Failure, Pedal Edema, Proteinuria, Hyperpotassemia, Leukocytosis and Hypophosphatemia. Review of the Multi-disciplinary Problems revealed no nursing care plan developed for the care related to any of the admitting diagnoses except Cardiac Nutrition Education. During an with Instructional Designer #1 at 0942 on 01/28/15 the above findings were verified.

D. Review of the clinical record of Patient #13 revealed an admission date of 01/23/15 with admission diagnoses which included Neuropathy, Abdominal Distention, Acute Renal Failure, Quadriplegia, DM, HTN, Severe Sepsis with Acute Organ Dysfunction, Altered Mental Status, Acute Encephalopathy, Acute Respiratory Failure, Hypokalemia, Anemia and Chronic Hypercapnia Respiratory Failure. Review of the Multi-disciplinary Problems revealed the only problem care planned related to the care of any of the admitting diagnoses was Fall Risk. During an interview with Instructional Designer #1 at 1112 on 01/28/15 the above findings were verified.

E. Review of the clinical record of Patient #15 revealed an admission date of 01/20/15 with admission diagnoses which included Vertebral Compression Fracture, Depression, Sepsis, Severe Sepsis with Acute Organ Dysfunction, Pyelonephritis, Acute Kidney Injury, Duodenal Ulcer with Hemorrhage, Melena, GI (gastrointestinal) bleed, Pancreatic mass, Nonsustained Ventricular Tachycardia, Duodenal Mass, Leukocytosis and Pneumonia. Review of the Multi-disciplinary Problems revealed none of the care related to the care of the admitting diagnoses was care planned except for Sepsis and Severe Sepsis with Acute Organ Dysfunction. During an interview with Instructional Designer #1 at 1153 on 01/28/15 the above findings were verified.