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Based on policy review, medical record review and interview, nursing care plans are not completed timely and/or do not address nursing interventions required to meet the needs for 7 of 17 patients (Patient # 1, 2, 9, 11, 14, 16, 25). This could lead to an adverse patient event due to unidentified patient care concerns.

Findings include:

Review of policy "Patient Care Plan, #CC.06.005", effective 02/15/17 indicates the plan of nursing care will be continued through discharge and is part of the record. Complete a patient assessment based on objective and subjective information and analyze the data to determine which nursing diagnosis will guide your patient care. Address all the patient's significant needs. Nursing care plans are to be customized and avoid "standardizing" care plans.

Review of policy "Aspiration Precautions Guidelines, #CC.15.017.01", effective date 12/13/11 revealed the Plan of Care is to include interventions required. If risk factors are identified, nursing will complete the dysphagia screen and initiate and document interventions and patient response.

Review of the medical record for Patient #1 revealed physician orders dated 03/21/17 at 07:17 PM for a cardiac low fat, 2-3 gm sodium diet with no caffeinated beverages. Food is to be cut in ½ inch pieces. The nursing plan of care, dated 5 days later on 03/26/17 at 07:31 AM indicates to educate Patient #1 on aspiration prevention. However, Patient #1 is profoundly mentally & physically disabled, requires assistance with all activities of daily living including the need to be fed. Additionally, the patient is unable to make her needs known and all decisions are made by representatives of the New York State Office for People with Developmental Disabilities.

Review of the medical record for Patient #2 revealed a dysphagia evaluation dated 06/26/18 at 09:36 AM indicating a mild risk of aspiration. Nursing care interventions include having Patient #2 sit fully upright at meals, alternate solid foods and liquids and take small bites. The nursing plan of care, dated 06/27/18 at 11:08 AM, indicates a risk of aspiration, but does not list recommended nursing interventions.

Review of the medical record for Patient #9 revealed a speech daily note dated 06/25/18 at 10:14 AM recommending full supervision with meals and feeding assistance as needed. Patient #9 is to be fully upright during meals and for 30 minutes after. Alternate purees and liquids. Patient #9 is to take small bites and small, single sips. Monitor swallowing. Pills to be crushed in puree. Discontinue oral intake and notify the physician if coughing and choking is observed. The nursing plan of care, dated two days later 06/27/18 at 02:06 PM, indicates a risk of aspiration but does not list recommended nursing interventions.

Review of the medical record for Patient #11 revealed physician orders dated 06/25/18 at 04:52 PM for aspiration precautions. A dysphagia evaluation dated 06/26/18 at 10:30 AM indicates a mild risk of aspiration. Full supervision is required with meals and assistance with feeding as needed. Patient #1 is to be fully upright during meals and for 30 minutes after. Patient #11 is to take small bites and single sips. The nursing care plan, dated 06/27/18 at 10:23 AM, indicates a risk of aspiration, but does not list recommended nursing interventions.

Review of the medical record for Patient #14 revealed a dysphagia evaluation dated 06/25/18 at 12:58 PM indicating a mild risk of aspiration. Nursing care interventions include having Patient #14 sit upright at meals/medication. The nursing plan of care, dated 06/27/18 at 11:09 AM, indicates a risk of aspiration, but does not list recommended nursing interventions.

Review of the medical record for Patient #16 revealed a dysphagia evaluation dated 06/13/18 at 02:30 PM indicating a mild risk of aspiration. Nursing care interventions include providing verbal cues and to have Patient #16 fully upright for 90 minutes during all oral intake. The nursing plan of care, dated 06/27/18 at 10:24 AM, indicates a risk of aspiration, but does not list recommended nursing interventions.

Review of the medical record for Patient # 25 revealed a History & Physical assessment dated 06/27/18 indicates Patient #25 is developmentally disabled, non-verbal and had a history of seizures. The nursing plan of care dated 06/27/18 does not indicate address seizure precautions/interventions and the need for assistance with all activities of daily living. Additionally, the patient is unable to make his needs known and all decisions are made by representatives of the New York State - Office for People with Developmental Disabilities.

Interview on 06/28/18 at 02:00 PM with Staff (A), Chief Nursing Officer and Staff (G), RN Quality Coordinator verified these findings.