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Based on clinical record review and interview, it was determined the facility failed to develop individualized nursing care plans consisting of interventions and goals for the patient care provided for 8 (#1, #4-10) of 10 (#1-10) patients. The failed practice had the potential to affect the nursing care provided to all patients admitted to the facility. The findings follow:

A. Patient #1: Review of the clinical record on 09/09/10 revealed the patient had a "Problems" list. The problems listed were cardio-pulmonary management, comfort management, wound and skin, comfort level, safety, cardiac monitoring, altered bowel patterns, comfort, wound and skin assessment and circulatory management. There was no evidence provided of the patient's goals or the interventions needed to resolve the patient's problems.
B. Patient #4: Review of the clinical record revealed the patient had a "Problems" list. The problems listed were comfort level, cardiac monitoring, safety, wound care management, pain management and hemodynamic monitoring. There was no evidence provided of the patient's goals or the interventions needed to resolve the patient's problems.
C. Patient #5: Review of the clinical record revealed the patient had a "Problems" list. The problems listed were hypertension due to renovas.., intake and output monitoring, safety, hemodynamic monitoring, cardiovascular monitoring, respiratory monitoring and comfort level. There was no evidence provided of the patient's goals or the interventions needed to resolve the patient's problems.
D. Patient #6: Review of the clinical record revealed the patient had a "Problems" list. The problems listed were pacer site/left chest monitoring, comfort level and education. There was no evidence provided of the patient's goals or the interventions needed to resolve the patient's problems.
E. Patient #7: Review of the clinical record revealed the patient had a "Problems" list. The problems listed were shortness of breath, comfort, skin condition, safety and wound and skin care. There was no evidence provided of the patient's goals or the interventions needed to resolve the patient's problems.
F. Patient #8: Review of the clinical record revealed the patient had a "Problems" list. The problems listed were cardiac monitoring, comfort, safety and smoking cessation education. There was no evidence provided of the patient's goals or the interventions needed to resolve the patient's problems.
G. Patient #9: Review of the clinical record revealed the patient had a "Problems" list. The problems listed were respiratory monitoring, heart rate monitoring, safety, education, comfort level, blood pressure management and urine output monitoring. There was no evidence provided of the patient's goals or the interventions needed to resolve the patient's problems.
H. Patient #10: Review of the clinical record revealed the patient had a "Problems" list. The problems listed were safety, comfort, cardiac monitoring, edema, skin assessment and hemodynamic monitoring. There was no evidence provided of the patient's goals or the interventions needed to resolve the patient's problems.
I. In an interview with the ICU (Intensive Care Unit) Nurse Leader on 09/09/10 at 1105, she stated the facility did not use care plans or have a list of individualized interventions needed for each problem on the patient's problem list.
J. The findings were confirmed in an interview with the ICU Nurse Leader and the Step-Down Nurse Leader on 09/09/10 at 1400.