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Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by:

1. The facility failed to follow regulatory standards (State and Federal_ and facility's staffing and patient care plan regarding safe patient care assignments for six (6) of six sampled charge nurses (CN 4, 5, 6, 7, 8 and 9) by assigning the charge nurses to direct patients care (the first line supervision of direct patient care; the provision of health care services directly to individuals being treated for, or suspected of having, physical or mental illnesses. Direct patient care includes preventive care) and telemonitoring technician (health professionals who monitor heart rhythms and places a patient on the heart monitoring machine) duties.

This deficient practice had the potential to result in patient needs not being met to assure patient safety especially during an emergency situation, and the charge nurse was not readily available to assist the staff (Registered Nurse). (Refer to A-0392)

2. The facility staff failed to complete assessments (a head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient's overall condition) for three (3) of thirty (30) sampled patients (Patient 3, Patient 4, and Patient 27) within four hours of the start of the shift in accordance with the facility's policy and procedure.

This deficient practice has the potential to result for delayed assessment, to provide care, and treatment for changes of condition for Patient 3, Patient 4, and Patient 27. (Refer to A-0395)

3. The facility failed to develop and implement a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for four out of thirty (30) sampled patients (Patient 2, Patient 9, Patient 19, and Patient 22) in accordance with the facility's policy and procedures regarding care plan development.

This deficient practice had the potential to result in Patient 2, Patient 9, Patient 19, and Patient 22's treatment and care goals not being met by not identifying their individualized patient care needs and risks. (Refer to A-0396)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to follow regulatory standards (State and Federal) and facility's staffing and patient care plan regarding safe patient care assignments for six (6) of six sampled charge nurses (CN 4, 5, 6, 7, 8 and 9). The six charge nurses were assigned direct patients care (the first line supervision of direct patient care; the provision of health care services directly to individuals being treated for, or suspected of having, physical or mental illnesses. Direct patient care includes preventive care) and telemonitoring technician (health professionals who monitor heart rhythms and places a patient on the heart monitoring machine) duties.

This deficient practice had the potential to result in the unit without proper accountability on addressing patient needs and safety especially during an emergency because the charge nurse for the unit has multiple roles.

Findings:

During an interview with Charge Nurse 2 (CN 2) on 1/25/2024 at 3:23 p.m., CN 2 stated, "Here in the ICU (intensive care units, a unit in a hospital providing intensive care for critically ill or injured patients), the charge nurse would be assigned to care for one to two patients and will also be the charge nurse on the same shift." CN 2 stated she was assigned as charge duties and was also assigned to direct patient care. CN 2 stated charge duties, she would check the crash cart (emergency supplies and medication cart), check the temperature for the warmer and medication refrigerator, complete acuity sheets, answer calls from the emergency department, assist in procedures if a patient condition became urgent, for example, intubation (the insertion of a tube into the windpipe to aid in breathing), and do a monitor technician job. CN 2 confirmed that she was assigned direct care of two patients and was the charge nurse for that shift. CN 2 stated she and the other registered nurses would not have time for a full meal, and she would take a quick bite in the back room.

A record review of the ICU nursing assignment schedule's record, "ICU Staffing Sheet," dated 12/31/2023, indicated CN2 was assigned to charge nurse responsibilities and direct care of a patient in room 3. The record also indicated, "Charge Note: The charge nurse will be the Rapid Response Team leader (a lead for the team of medical emergency clinicians in the response to medical emergencies, provide rapid assessment, and deploy resources for patients who are experiencing acute clinical deterioration in the hospital) when called upon."

During a concurrent observation and record review, on 1/26/2024 at 1:22 p.m. on the ICU (Intensive care unit, is a part of a hospital that gives care to people who are critically ill), ten (10) patients were observed on the unit. A review of the unit assignment indicated CN 1 was assigned to direct patient care for a patient in Room 10 (Patient 30). CN 1 observed preparing medication to prepare for intubation (the process of inserting a tube into the airway [windpipe] to aid breathing) for another patient in Room 7.

During an interview with Registered Nurse (RN) 2, who was one of the registered nurses working in the ICU, on 1/26/2024 at 1:22 p.m., RN 2 stated CN1 was assigned to direct patient care (Patient 30). RN 2 stated charge nurses in the ICU were assigned to direct patient care and function as charge nurses. RN 2 stated they (CNs) were also assigned to telemetry monitoring (a specially trained nurse monitors continuously transmitted data, such as the heart rate, breathing, and blood pressure, and can respond to any changes that signal a potential problem).

A record review of the ICU nursing assignment schedule's record, "ICU Staffing Sheet," dated from 12/1/2023 through 12/13/2023, and 1/14/2024 through 1/20/2024, the "ICU Staffing Sheet" indicated, "Charge Note: The charge nurse will be the Rapid Response Team Leader when called upon." The ICU Staffing Sheet indicated the following:

1. On 12/2/2023, day shift (7 p.m. - 7 a.m.), CN 6 was assigned charge duties and was also assigned direct care of two patients, who were patients in room 2 and room 7.

2. On 12/4/2023, day shift (7 a.m. - 7 p.m.), CN 7 was assigned charge duties and was also assigned direct care of two patients, who were patients in Room 2 and Room 6.

3. On 12/5/2023, day shift (7 a.m. - 7 p.m.), CN 7 was assigned charge duties and was also assigned direct care of two patients, who were patients in Room 2 and Room 9.

4. On 12/5/2023, night shift (7 p.m. - 7 a.m.), CN 6 was assigned charge duties and was also assigned direct care of a patient in Room 8.

5. On 12/8/2023, day shift (7 a.m. - 7 p.m.), CN 7 was assigned charge duties and was also assigned direct care of two patients, who were patients in Room 2 and Room 3.

6. On 12/9/2023, day shift (7 a.m. - 7 p.m.), CN 8 was assigned charge duties and was also assigned direct care of a patient in Room 2.

7. On 12/12/2023, night shift (7 p.m. - 7 a.m.), CN 6 was assigned charge duties and was also assigned direct care of a patient in Room 2.

8. On 12/13/2023, day shift (7 a.m. - 7 p.m.), CN 9 was assigned charge duties and was also assigned direct care of two patients, who were patients in Room 3 and in Room 7.

9. On 1/17/2023, night shift (7 p.m. - 7 a.m.), CN 6 was assigned charge duties and was also assigned direct care of a patient in Room 2.

10. On 1/18/2023, night shift (7 p.m. - 7 a.m.), CN 5 was assigned charge duties and was also assigned direct care of patients, who were in Room 6 (from 7 p.m. - 10:10 p.m.), patient in Room 7, and patient in Room 3 (from 4:10 a.m. - 6:05 a.m.).

11. On 1/19/2023, night shift (7 p.m. - 7 a.m.), CN 4 was assigned charge duties and was also assigned direct care of a patient in Room 9.

12. On 1/20/2023, night shift (7 p.m. - 7 a.m.), CN 4 was assigned charge duties and was also assigned direct care of two patients, who were patients in Room 9 and Room 10.

During a concurrent interview and record review, on 1/26/2024 at 5:40 p.m. with the Chief Nursing Officer (CNO), the CNO stated, "The facility followed staffing ratios (maximum number of patients assigned to a Registered Nurse [RN] during one shift) as per Title 22, State Regulations." The CNO reviewed the Barclays California Code of Regulations (current through 1/26/24 Register 2024), under Title 22, Division 5, Chapter 1, Article 3, Section (a), which indicated, "Nurse Administrators, Nurse Supervisors, Nurse Managers, and Charge Nurses, and other licensed nurses shall be included in the calculation of the licensed nurse-to-patient ratio only when those licensed nurses are engaged in providing direct patient care. When a nurse administrator, nurse supervisor, nurse manager, charge nurse, or other licensed nurse is engaged in activities other than direct patient care, that nurse shall not be included in the ratio." The CNO stated, "We are not aware of this (the charge nurse will not be counted in the ratios if the charge nurse is engaged in activities other than direct patient care)."

A record review of the facility's policy and procedure (P&P) titled, "Staffing Plan," dated January 2024, the P&P indicated, "Staffing patterns have been developed to include the base staffing requirements identified by Title 22 (Addendum 8) and acuity-based staffing standard ...The charge nurse will document the patient acuity level on the Patient Assignment Sheets. Patient Classification: Patient Classification will provide a method of determining nursing care needs of each individual patient based on the beside nurse assessment. Staffing will be determined on a shift-by-shift basis using the staff to patient ratio as determined in Title 22 section 70217. Patient Classification will be used to access the need for additional staff and in making balanced staff assignments ... The acuity will be called to the staffing office in preparation for the upcoming shift's staffing ..."

A record review of the facility's policy and procedure (P&P) titled, "Plan for Provision of Patient Care," dated October 2023, the P&P indicated the following: Staffing plans for patient care departments are based on the level and scope of care that needs to be provided, the frequency of care to be provided, and a determination of the level of staff that can most competently, comfortably confidently, and effectively provide the type of care needed. Minimum nurse patient ratios are based on the California Department of Health regulations ... Anticipated changes in the patient care delivery system may necessitate delegation of patient care planning, as indicated, to organizational departments with patient care responsibilities. These will include all disciplines involved in the type of services undergoing change ... Staffing Plans for Patient Care: Nursing: Principles underlying the plan for the provision of nursing care included the following:

1. A Registered Nurse (RN) plans, delegates, and coordinates nursing care provided in every area throughout the hospital

2. Consistent Standards of Patient care and Standards of Nursing Practice were used to monitor and evaluate the quality and relevance of nursing care provided

3. Charge Nurse - The Charge Nurse functions as the assistant to the Department Director/Manager. The Charge Nurse was responsible for unit activities and documentation for the duration of his/her shift. The Charge Nurse monitors activities on his/her shift and consults with the Department Director or Administrative House Supervisor as necessary. The Charge Nurse was accountable to the Department Director/Manager.

Based on observation, interview, and record review, the facility staff failed to complete assessments (physical [a head to toe assessment] and psychosocial [an individual's mind or behavior, and to the interrelation of behavioral and social factors] assessment) for three (3) of thirty (30) sampled patients (Patient 3, Patient 4, and Patient 27) within four hours of the start of the shift in accordance with the facility's policy and procedure.

This deficient practice has the potential to result in delayed assessment (physical and psychosocial), to provide care, and treatment for changes of condition for Patient 3, Patient 4, and Patient 27.

Findings:

a. A record review of Patient 3's History and Physical (H&P, a physician's examination record of a patient), dated 12/15/2023, indicated Patient 3's medical history included alcohol abuse and hypertension (high blood pressure). The H&P indicated, Patient 3 was "Positive for recent fatigue (tired), confusion, but Patient 3 was appearing to be in mild withdrawals (the physical and mental symptoms that a person has when they suddenly stop or cut back the use of an addictive substance) " The H&P indicted Patient 3's blood pressure was 165/71 mmHg (millimeter of mercury, a unit of measurement, normal blood pressure between 90/60 mmHg and 120/80 mmHg), and Patient 3's "Prognosis (likely outcome) is guarded (being an extremely serious condition)."

During a concurrent interview with Wound Care Consultant and staff coordinator (Registered Nurse, RN 6) and record review of Patient 3's Medical Surgical Telemetry (MST) Shift Assessment (a comprehensive physical examination and health evaluation of a patient's entire body), on 1/24/2024 at 3:03 p.m., Patient 3's Medical, Surgical, Telemetry (MST, unit for patient requiring medical, surgical, and [Telemetry, care in a hospital where patients undergo continuous heart monitoring) Shift Assessment indicated Patient 3's shift assessment was completed on 12/16/2023 at 2:35 a.m. RN 6 stated, "The shift assessment should be completed within four hours after the shift started, and shift started at 7 p.m." RN 6 stated the RN has four hours from the beginning of the shift to enter their assessment. RN 6 stated, Patient 3's assessment was late (Start of shift was on 12/15/2023 at 7 p.m. and assessment was completed on 12/16/2023 at 2:35 a.m. [7 hours and 35 minutes]).

During an interview, on 1/25/2024 at 2:34 p.m. with Charge Nurse (CN 1) of the Medical, Surgical (specialty that cares for patients with complex medical and surgical conditions in the hospital), and Telemetry (Patient with heart monitoring) Unit , CN 1 stated, "The start of the shift (start of nursing shift) is between 7:00 a.m. and 7 p.m., and assessments (physical and psychosocial), should be entered within 4 hours of the start of the shift."

During an interview on 1/25/2024 at 3:00 p.m. with Registered Nurse (RN) 5, RN 5 stated, "Assessment is important to enter prior to four hours, as we need to have a baseline (information or data gathered at the beginning of a period from which variations that subsequently develop are compared) of patient condition, and if there are changes, we will be able to know."

b. A record review of Patient 4's "Face Sheet (one-page summary of important information about a patient)," undated, indicated Patient 4 was admitted on 12/13/23 at 9:44 p.m. to the medical surgical service.

A record review of Patient 4's "History and Physical," dated 12/14/2023, indicated, Patient 4 medical history included diabetes mellitus (having high blood sugar level in the body), hypertension, left breast mass, and facial basal cell carcinoma (skin cancer on the face). The H&P indicated Patient 4, "Presented to the Emergency Room with generalized weakness, failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity) for cellulitis (bacterial skin infection that causes redness, swelling, and pain in the infected area) of the left side of the chest wall."

During a concurrent interview and record review, on 1/24/2024 at 3:03 p.m. with the Wound Care Consultant and staff coordinator (RN 6), Patient 4's Medical Surgical Telemetry (MST) Shift Assessment (a comprehensive physical examination and health evaluation of a patient's entire body), dated 12/15/2023 indicated Patient 4's assessment was completed on 12/15/2023 at 2:11 a.m. RN 6 stated, "This assessment (Patient 4's assessment) is over three hours late, it (Patient 4's assessment) should be done within the four hours of shift start (Start of shift was on 12/14/2023 at 7 p.m. and shift assessment was completed at 12/15/2023 at 2:11 a.m. [7 hours and 11 minutes])."

During an interview on 1/25/2024 at 2:34 p.m. with charge nurse of the medical surgical and telemetry unit (CN) 1, CN 1 stated, "The shift is between 7:00 a.m. and 7 p.m., and assessments should be entered within 4 hours of the start of the shift."

c. A record review of Patient 27's "Face Sheet," undated, the face sheet indicated Patient 27 was admitted on 12/3/2023 at 00:03 (12a.m.) to the Medical and Surgical Unit and was discharge on 12/6/2023 at 3:35 p.m.

A record review of Patient 27's "History and Physical," dated 12/3/2023, indicated, Patient 27's presented to the ER for flu-like symptoms. The patient states he had been feeling sick since yesterday complaining of fever, muscle ache, generalized weakness, cough, congestion. Patient 27 had a fever of 102 degrees Fahrenheit (normal body range, from 97°F [Fahrenheit] to 99°F) on the morning of admission. Patient 27's wife was concerned and called EMS (emergency medical service, a system that provides emergency medical care). The record indicated family reported that Patient 27 was so weak and tired, and Patient 27 could not stand up to walk. The record indicated Patient 27 denied any nausea, vomiting, abdominal pain, diarrhea, chest pain, shortness of breath, or difficulty breathing.

During a concurrent interview, with RN 11, and record review of Patient 27's Medical Surgical Telemetry (MST) Shift Assessment), on 1/25/2024 at 11:20 a.m., Patient 27's "Medical Surgical Telemetry (MST) Shift Assessment," indicated Patient 27's shift assessment was completed, on 12/5/2023 at 11:21 a.m. RN 11 stated, "The shift assessment should be completed within four hours of shift start and shift start at 7 a.m." RN 11 stated RN has four hours from the beginning of the shift to enter their shift assessment. RN 11 stated Patient 27's shift assessment was late (Start of shift was on 12/5/2023 at 7 a.m. and shift assessment was completed on 12/5/2023 at 11:21 a.m. [4 hours and 11 minutes]."

A record review of the facility's policy and procedure (P&P) titled, "Assessment & Reassessment-Patient." dated January 2024, the P&P indicated...A registered nurse assesses the patient's needs for nursing care in all settings where nursing care is provided. Nurses will complete assessments on the inpatient units within four hours of patient arrival and/or within four hours of the start of their shift. Additional assessments will be determined from the initial assessment's department-specific criteria for patient type, and/or by other discipline consultation."

A record review of the facility's P&P titled, "Plan For Provision of Patient Care," dated October 2023, indicated, "A complete physical and psychosocial assessment of the patient through interview, observation, inspection, auscultation, palpation and reports as performed by the RN within the time frame outlined in the Assessment/Reassessment Policy."

Based on interview and record review, the facility failed to develop and implement a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for four out of thirty (30) sampled patients (Patient 2, Patient 9, Patient 19, and Patient 22) in accordance with the facility's policy and procedures regarding care plan development.

This deficient practice had the potential to result in Patient 2, Patient 9, Patient 19, and Patient 22's treatment and care goals not being met by not identifying their individualized patient care needs and risks.

Findings:


a. A record review of Patient 2's "Face Sheet (one-page summary of important information about a patient)," undated, indicated Patient 2 was admitted on 12/15/2023 at 2:25 p.m. to the Telemetry service (specialty that cares a floor in a hospital where patients undergo continuous heart monitoring).

A record review of Patient 2's "History and Physical (H&P, a physician's examination record of a patient)," dated 12/15/2023, indicated, Patient 2 medical history includes coronary artery disease (plaque buildup in the wall of the arteries that supply blood to the heart) and cardiac (relating to the heart) complaints along with hypertension (high blood pressure). The record indicated Patient 2 was brought in by EMS (emergency medical service, (emergency medical service, a system that provides emergency medical care) after becoming very dizzy while sitting at home and stated Patient 2 had some chest pressure.

During a concurrent interview with the Wound Care Consultant and staff coordinator (Registered Nurse, RN 6), and record review of Patient 2's Medication Administration Record (MAR), on 1/24/2024 at 2:43 p.m. with Patient 2's "Medication Administration Record (MAR)," dated 12/15/2023 was reviewed and indicated, on 12/15/2023, Patient 2 was given 2 milligram (mg, unit of measurement) of an intravenous (IV, into the vein) Morphine (a pain medication) for head pain. The record indicated Patient 2's pain level rate on a numeric pain rating scale (a 0 [zero] - 10 scale, with zero meaning "No pain," and 10 meaning "The worst pain imaginable.") was at 8 out of 10. The MAR indicated Patient 2 was given a dose of 2 mg IV Morphine. The record indicated the following day, on 12/16/2023, Patient 2 had a pain level rate was 7 out of 10. RN 6 stated the prescribed order for Morphine was a PRN (as needed) order.

During a concurrent interview with RN 6, and record review of Patient 2's Care Plan records, on 1/24/2024 at 2:45 p.m., Patient 2's Care Plan, dated 12/18/2023 was reviewed by RN 6 and RN 6 show Patient 2' care plan. The record indicated no care plan was developed to addressed Patient 2' pain. RN 6 stated, "Patient 2 should have a pain care plan as she is on a PRN, Morphine."

During a review of the facility's policy and procedure (P&P) titled, "Plan for Provision of Patient Care," dated October 2023, the P&P indicated, "Standard of Care: Patient Care/Nursing Process: Patients are entitled to receive safe care which reflects an ongoing use of the Nursing process based on their specific care needs. All patients can expect to have their physiologic and psychosocial health status assessed upon admission for the purpose of formulating nursing diagnoses and development of a plan of care that describes nursing actions necessary to achieve patient goals. Systems assessments should also include mobility, rest, and pain management to facilitate a satisfactory level of comfort. This plan will be individualized, multidisciplinary, and continually evaluated and adapted as patient needs change ...Nursing interventions will be performed in response to identified problems/needs and referrals to other disciplines made as necessary ... Nursing diagnoses are derived from health status data, i.e., the patient's health status is compared to the norm; capabilities and limitations are identified. The Registered Nurse will initially date and initial all problem lists ... Implementation of the plan of care is necessary to achieve desired outcomes ..."

b. A record review of Patient 9's "History and Physical (H&P)," dated 12/9/2023, indicated, Patient 9 presented to the emergency room accompanied by her daughter for evaluation of dysuria (painful or difficult urination). The H&P indicated, "Plan: admit, IV antibiotics (medicines that fight bacterial infections), and renal ultrasound (uses sound waves to examine the kidneys and bladder)."

During a concurrent interview with Charge Nurse 1 (CN 1) and record review of Patient 9's "Medication Administration Record," on 1/25/2024 at 1:50 p.m., Patient 9's "Medication Administration Record (MAR)," dated 12/9/2023,indicated that on 9/12/2023 at 12:20 a.m., Patient 9 received fifty (50) milliliters (mL, unit of measurement) of piperacillin and tazobactam (a medication used to treat many different infections) intravenous for a urinary infection.

During a concurrent interview with CN 1 and record review of Patient 9's medical records and "Care Plans," on 1/24/2024 at 2:45 p.m. CN 1 showed the screen for Patient 9's "Care Plan," but the screen indicated there was no care plan initiated for Patient 9. CN 1 stated, "There should be a care plan initiated as soon as possible once the patient is admitted." CN 1 confirmed that Patient 9 did not have care plans developed that reflect Patient 9' care and needs. CN 1 also confirmed that it (care plan) was important for urinary infections, as it was evident that Patient 9 was receiving IV antibiotic medications to treat urinary infection.

During a review of the facility's policy and procedure (P&P) titled, "Plan for Provision of Patient Care," dated October 2023, indicated, "Standard of Care: Implementation of the plan of care is necessary to achieve desired outcomes." The policy and procedure indicated formulation of nursing actions to be taken were consistent with established interdisciplinary plan of care. The Registered Nurse plans and collaborates with other disciplines to ensure the patient will be able to demonstrate understanding of medical and nursing interventions associated with the patient's diagnosis. The delivery of safe and quality nursing care included accurately reported, documented patient's symptoms, and progress in the medical record. Nursing assigned responsibility for patients during the shift was to ensure that the basic needs of patients were met and notification of the physician of any unexpected changes in the patient's condition. Nurses to initiate appropriate nursing intervention which might be required to stabilize a patient's condition and/or prevent complications. Nurses to execute of all medical orders written by the physician. The nurse's knowledge of the rationale for the effects of and the proper administration of the medications and/or treatments he/she administers.

c. A record review of Patient 19's "History and Physical (H&P)," dated 12/2/2023, indicated, Patient 19' presented to the ER (Emergency Room) with hematemesis (vomiting of blood) for 2 days. Patient was just recently discharged from the Hospital for GI ([Gastrointestinal] relating to both stomach and intestine) bleeding. The H&P plan indicated monitoring of Hemoglobin (the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues) and Hematocrit (test measures the proportion of red blood cells in the blood) every 12 hours.

During a concurrent interview with RN 4and record review of Patient 19 medical records and Care Plan record, on 1/24/2024 at 2:00 p.m. Patient 19's electronic medical record was reviewed with RN 4 and RN 4 verified Patient 19 had no care plan initiated for Patient 19 that addresses her bleeding on admission. RN 4 stated, "Patient came with a diagnosis of gastrointestinal bleed on admission 12/1/23, a care plan should be initiated and developed on 12/1/23." RN 4 stated it (care plan) was important that a care plan was developed for GI bleed and stated Patient 9 was receiving blood transfusion to treat blood loss.

d. A record review of Patient 22's "History and Physical (H&P)," dated 12/6/2023, indicated, Patient 22 presented to the ER (Emergency Room) with a chief complaint of back pain. Patient 22 presented to the ER a day before (12/5/2023) admission with similar complaints and left without being seen. The record indicated Patient 22's pain reportedly worsened on the morning of admission (12/6/2023), so she returned to the ER. The record indicated Patient 22 had not been seen for this problem and has not taken any medications. Patient 22's husband reports the patient fell off the toilet day before. The record indicated the plan was to admit Patient 22to Medical/Surgical Unit and to obtain Magnetic Resonance Imaging ([MRI] a medical imaging technique that uses a magnetic field and computer-generated radio waves to create detailed images of the organs and tissue.) of lumbar spine (consists of the five bones vertebra in a person's lower back).

During a concurrent interview with RN 11 and record review Patient 22's medical records and Care Plans, on 1/25/2024 at 10:28 a.m., Patient 22's electronic medical record was reviewed by RN 11 and verified Patient 22 had no care plan initiated to address Patient 22's pain. RN 11 stated, "Patient came with a chief complaint of back pain, a care plan should be initiated and developed immediately on admission." RN 4 also confirmed that it (care plan) was important be developed for pain management. RN 11 stated Patient 22 was receiving pain medication for pain management.

During a review of the facility's policy and procedure (P&P) titled, "Plan for Provision of Patient Care," dated October 2023, indicated, "Standard of Care: Implementation of the plan of care is necessary to achieve desired outcomes." The policy and procedure indicated formulation of nursing actions to be taken were consistent with established interdisciplinary plan of care. The Registered Nurse plans and collaborates with other disciplines to ensure the patient will be able to demonstrate understanding of medical and nursing interventions associated with the patient's diagnosis. The delivery of safe and quality nursing care included accurately reported, documented patient's symptoms, and progress in the medical record. Nursing assigned responsibility for patients during the shift was to ensure that the basic needs of patients were met and notification of the physician of any unexpected changes in the patient's condition. Nurses to initiate appropriate nursing intervention which might be required to stabilize a patient's condition and/or prevent complications. Nurses to execute of all medical orders written by the physician. The nurse's knowledge of the rationale for the effects of and the proper administration of the medications and/or treatments he/she administers.