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Based on review of the facility's policy and procedures, record review and staff interview it was determined the facility failed to ensure the nursing staff kept current and revised a nursing care plan for one (#1) of three patients sampled.

Findings include:

Review of the medical record for patient #1 revealed the patient was admitted to the facility on 4/26/10 for chest pain. Review of the history and physical revealed a past medical history of Coronary Artery Disease, Hypertension, Diabetes Mellitus type II, Osteoarthritis, Morbid Obesity, and Osteoporosis. Review of the nursing documentation revealed nursing completed an assessment and history upon admission to the unit. Nursing documented the patient was at high risk of falls. Based on the nursing assessment a nursing care plan was developed and initiated. Nursing did not identify the problem of high risk for falls on the nursing plan of care. Review of the medical record revealed the patient had Coronary Artery Bypass surgery on 5/03/10. Review of the nursing assessment of the patient on 5/04/10 revealed the patient was identified as a risk for falls. Review of the MAR (Medication Administration Record) revealed the patient received narcotic pain medication and nursing documented the patient required two staff members to assist the patient to transfer from the bed to the chair. Review of the nursing plan of care revealed an RN (Registered Nurse) reviewed the plan of care daily. Nursing did not revise the plan of care to identify the problem of high risk for falls following the nursing assessment which identified the patients increased nursing needs. Review of the nursing documentation on 5/07/10 at 5:00 a.m. revealed the patient required a 2 staff assist up to the chair. Nursing documented the patient was " unable to perform " and the ARJO (used for patient lifting and transfers) was required. Nursing documentation revealed the patient was unable to bear weight while being transferred on 5/07/10 at 5:00 a.m. from the bed to the chair with 2 nurses assisting the patient. The patient slid to the floor. The patient then required to be lifted from the floor to the chair with the ARJO lift. Review of the patient's plan of care on 5/07/10 revealed the plan was revised at 6:48 a.m. to include the identified problem of risk for falls. Review of the facility's policy, "Assessment/Reassessment", last revised 6/09, indicates the plan of care will be regularly reviewed every day for effectiveness and revised as needed based on the patient's condition. Nursing failed to revise the patient's plan of care following the nursing assessment on 4/26/10 which identified the patient at high risk for falls. Interview with the Director of Quality Management on 7/27/10 confirmed the above findings.