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Based upon record review and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 485.623(c)(1), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include:

See the following K-tags on the CMS-2567

K-0712

Based on document review and interview the facility failed to ensure appropriate provision of services were met as evidenced by the failure to document a nursing care plan in the patients medical record for five of nine (# 14, 16, 17, 18, & 19) inpatient medical records reviewed, resulting in the potential failure to provide individualized goal directed nursing care for inpatients treated at this facility. See the specific citation:

0298 - Failure to develop and keep current a nursing care plan

Based on document review and interview the facility failed to ensure that patients had a nursing care plan documented in the medical record for five of nine (# 14, 16, 17, 18,&19) inpatient medical records reviewed from a total of 20 medical records reviewed, resulting in the potential failure to provide individualized goal directed nursing care for inpatients treated at this facility. Findings include:

On 06/07/2019 between 0900 and 1100 during electronic medical record review, the following was revealed:
Patient #14 was admitted on 03/14/2019 and discharged 03/19/2019, A nursing care plan could not be located in the medical record.
Patient #16 was admitted on 04/05/2019 and discharged 04/07/2019, A nursing care plan could not be located in the medical record.
Patient #17 was admitted on 04/12/2019 and discharged 04/13/2019, A nursing care plan could not be located in the medical record.
Patient #18 was admitted on 04/27/2019 and discharged 05/02/2019, A nursing care plan could not be located in the medical record.
Patient #19 was admitted on 05/18/2019 and discharged 05/19/2019, A nursing care plan could not be located in the medical record

On 06/07/2019 at 1100 staff A was interviewed, she was asked if a care plan is to be developed for every patient. Staff A stated "Yes, every patient is to have a care plan developed by the nurses and then they document to the plan once a shift (at minimum a total of two times per day as the facility staffs 12 hour shifts). Staff A went on to explain that in March they went live with their new electronic medical record and that the learning curve has been long for many of the staff. Staff A stated "I did not realize that there was a problem generating care plans."

On 06/07/2019 at 1300 the policy titled "Care Planning" #600-017 dated effective 05/09/2016 was reviewed. On page 1 of 2 under Procedure it states "Within eight (8) hours of admission all patients shall have a plan of care generated...The plan of care shall be individualized...The care plan shall be updated daily, with revisions reflecting the reassessment of the needs of the patient."

Based on document review and interview the facility failed to document evidence informed consent for treatment was obtained for three of nine (#14, 16, and 20) inpatients whose medical records were reviewed for consent, out of a total of 20 sampled patients, resulting in the potential for patients and/or patient representatives not being informed of the risks and benefits of treatments. Findings include:

On 06/07/2019 between 0900 and 1100 the following electronic medical records were reviewed with staff A:
Patient #14 a female admitted on 03/14/2019 and discharged 03/19/2019, A general consent and acknowledgement of the services she was about to under go could not be located in the medical record.

Patient #16 a female admitted on 04/05/2019 and discharged 04/07/2019, A general consent and acknowledgement of the services she was about to under go could not be located in the medical record.

Patient #20 a female admitted on 05/25/2019 and discharged 05/29/2019, A general consent and acknowledgement of the services she was about to under go could not be located in the medical record.

On 06/07/2019 at 11:00 staff A was interviewed, she was asked if a consent for treatment was obtained on every patient that is admitted. Staff A stated "Yes." When asked to explain whose responsibility it was to make sure a consent for treatment was documented in the clinical record Staff A stated, "It's the admitting Nurse."

On 06/07/2019 at 1330 the policy titled "Consents" #130-011/300-002 dated revised 04/30/2015 was reviewed. On page 1 of 6 under 1. Consent process it states "...the general consent or consent and acknowledgement, which is the agreement to routine hospital services, diagnostic procedures, and medical treatment...under 2. General Consent it states"...is a general consent signed be the patient, or his/her representative, in the presence of a hospital staff member at the time of, or shortly after, admission to the hospital. It provides a record of consent to routine hospital services, diagnostic procedures, and medical treatment..."