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Based on clinical record review and staff interview, the provider failed to document summary information regarding additional assessments performed through the resident assessment protocols for 4 (#s 1, 2, 3, 4) of 4 sampled patients. Findings included:

1. Patient #1 was admitted as a swing bed patient on 2/27/12; diagnoses included resolving pneumonia and status post a fall at home. The patient was also diabetic, had a long history of smoking and COPD (Chronic Obstructive Pulmonary Disease), chronic back pain and depression.

The patient presented with nutritional risk factors that included difficulty swallowing, poor appetite, diabetes, and chronic pain.

The dietary services manager made a chart entry on 2/28/12 that acknowledged the patient's poor appetite and the need to encourage food and fluid intake, a full liquid diet, and pain. However, a nutritional assessment was not completed by a qualified dietitian.

An Admission Database/Initial Assessment was completed on 2/27/12. The assessment process lacked identification of potential problems, strengths and preferences.

The assessment process did not include causal or risk factors for decline or lack of improvement. The assessment process and data were not utilized to develop a plan of care that addressed the patient's care needs.

2. Patient #2 was admitted as a swing bed patient on 4/7/11; diagnoses included repair of a fractured hip. The patient also had COPD, CHF (Congestive Heart Failure), dementia and was a hospice patient prior to admission to Ruby Valley Hospital. The attending physician documented in a progress note dated 4/5/11, that the goal of care was to, "get patient strong enough to mobilize, and work on getting him back home on hospice as quickly as possible."

An Admission Database/Initial Assessment was completed on 4/7/11. The admission assessment did not include a psychosocial evaluation or mention of the patient's hospice election.

The patient was prescribed the following psychotropic medications: Trazodone, Zoloft and Ativan. Psychotropic medication use was not addressed during the assessment process. Specifically with an unnecessary drug evaluation, an evaluation of treatable/reversible reasons for use of psychotropic drugs, and a depression screening.

3. Patient #3 was admitted as a swing bed patient on 4/1/11; diagnoses included repair of a fractured hip. The patient also had chronic anemia, CHF, dementia, and atrial fibrillation.

The patient required assistance with transfers, mobility, activities of daily living, and had two healing surgical incisions from the hip repair.

An Admission Database/Initial Assessment was completed on 4/1/11. The assessment process lacked identification of potential problems, strengths and preferences.

The assessment process did not include causal or risk factors for decline or lack of improvement. The assessment process and data was not utilized to develop a plan of care that addressed the patient's care needs.

4. Patient #4 was admitted as a swing bed patient on 9/2/11; diagnoses included repair of a fractured hip. The patient also had dementia, hypertension, and atrial fibrillation.

The patient was admitted for continued rehabilitation after a fractured hip, she had a history of a urinary tract infection, and on-going treatment for a calf wound.

An Admission Database/Initial Assessment was completed on 4/1/11. The assessment process lacked identification of potential problems, strengths and preferences.

The assessment process did not include causal or risk factors for decline or lack of improvement. The assessment process and data were not utilized to develop a plan of care that addressed the patient's care needs.

During an interview on 3/14/12 at 4:00 p.m., the assessment concerns were discussed with the DON (Director of Nurses). The DON stated the Admission Database/Initial Assessment was the extent of the providers admission comprehensive assessment.

Based on clinical record review, policy review, and staff interview, the provider failed to develop a comprehensive care plan for 4 (#s 1, 2, 3, and 4) of 4 sampled patients. Findings included:

1. Patient #1 was admitted as a swing bed patient on 2/27/12; diagnoses included resolving pneumonia and status post a fall at home. The patient was also diabetic, had a long history of smoking and COPD (Chronic Obstructive Pulmonary Disease), chronic back pain and depression.

An Admission Database/Initial Assessment was completed on 2/27/12. The assessment process lacked identification of potential problems. The assessment process and data were not utilized to develop a plan of care that addressed the patient's care needs.

The patient presented with nutritional risk factors that included difficulty swallowing, poor appetite, diabetes, and chronic pain. The patient's weight on admission (2/27/12) was 119.9 pounds. On 3/12/12, the patient's weight was 110 pounds. (Refer to C400)

The clinical record lacked a comprehensive plan of care that addressed the patient's current health needs that included weight loss, resolving pneumonia, recent fall, deconditioning, recent smoking cessation, and depression.

During an interview on 3/14/12 at 3:30 p.m., staff member B, a licensed nurse, stated every day the nurse identified focus areas of care for each patient. The care focus areas were the plan of care for that day. On 3/14/11 at 4:00 p.m., the DON (Director of Nurses) verified the daily care plan process.

The daily charting packet, described above, was approximately nine pages and included Patient Centered Goals and Interventions. The document included 29 Nursing Diagnoses, one of which was altered nutrition.

Altered nutrition was a potential nursing diagnosis, however, the staff had not selected nutrition as a focus area since admission.

2. Patient #2 was admitted as a swing bed patient on 4/7/11; diagnoses included repair of a fractured hip. The patient also had COPD, CHF (Congestive Heart Failure), dementia and was a hospice patient prior to admission to Ruby Valley Hospital. The attending physician documented in a progress note dated 4/5/11, that the goal of care was to, "get patient strong enough to mobilize, and work on getting him back home on hospice as quickly as possible."

An Admission Database/Initial Assessment was completed on 4/7/11. The assessment process lacked identification of potential problems. The assessment process and data were not utilized to develop a plan of care that addressed the patient's care needs.

The clinical record lacked a comprehensive plan of care that addressed the patient's current health needs that included decreased mobility secondary to a recent repair of a hip fracture, pain, fall risk, psychotropic medication use and need for monitoring, and end stage CHF and hospice services prior to hospitalization.

3. Patient #3 was admitted as a swing bed patient on 4/1/11; diagnoses included repair of a fractured hip. The patient also had chronic anemia, CHF, dementia, and atrial fibrillation.

An Admission Database/Initial Assessment was completed on 4/1/11. The assessment process lacked identification of potential problems, strengths and preferences.

The assessment process and data were not utilized to develop a comprehensive plan of care that addressed the patient's care needs that included altered mobility secondary to a recent repair of a fractured hip. (Refer to C397)

4. Patient #4 was admitted as a swing bed patient on 9/2/11; diagnoses included repair of a fractured hip. The patient also had dementia, hypertension, and atrial fibrillation.

An Admission Database/Initial Assessment was completed on 4/1/11. The assessment process lacked identification of potential problems, strengths and preferences.

The assessment process did not include causal or risk factors for decline or lack of improvement.

The assessment process and data were not utilized to develop a plan of care that addressed the patient's care needs that included altered mobility secondary to a recent repair of a fractured hip, recurrent urinary tract infections, and a wound on the right calf. (refer to C397)

5. The provider's Nursing Care Plan Policy was reviewed and included the following guidelines:
- "A nursing care plan must be developed and maintained for each inpatient . . . "
- "Implementation of the Nursing Care Plan shall begin on admission by the admitting nurse."
- "Continuation and revisions to the care plan shall be done daily and/or more frequently, as the patient's condition warrants."
- "The care plan will address nursing diagnosis, medications, treatments, specialized equipment needed, limitations in physical abilities, ADL's [Activities of daily living], goals of treatment and expected outcome."
- "The medical record will not be considered completed without a Nursing Care Plan."

Based on clinical record review and staff interview, the provider failed to meet professional standards related to comprehensive assessment and care plan development for 2 (#s 3 and 4) of 4 sampled patients. Findings included:

1. Patient #3 was admitted as a swing bed patient on 4/1/11; diagnoses included repair of a fractured hip. The patient also had chronic anemia, CHF, dementia, and atrial fibrillation.

The patient required assistance with transfers, mobility, activities of daily living, and had two healing surgical incisions from the hip repair.

An Admission Database/Initial Assessment was completed on 4/1/11. The assessment process lacked identification of potential problems, strengths and preferences. The assessment process and data were not utilized to develop a plan of care that addressed the patient's care needs.

According to the admission assessment dated 4/1/11, the patient had no skin breakdown. A skin assessment to evaluate risk for pressure ulcer development was completed on 4/1/11. The patient's score was 7, a score of 10 or greater indicated a need to institute skin care measures.

Based on review of the daily progress notes, the patient had no skin breakdown until 4/9/11. On 4/9/11 at 7:45 p.m., the licensed nurse documented a 2.5 cm (centimeter)
area of black eschar on the left heel.

A wound consultant evaluated the patient's wounds on 4/12/11. The wound nurse prescribed the application of Betadine solution in the morning and the evening, to the patient's left heel and the tips of two black toes. The clinical record lacked evidence the order was carried out.

The clinical record lacked a comprehensive assessment, comprehensive plan of care, and on the ninth day after admission the patient developed a 2.5 cm area of black eschar on her left heel.

2. Patient #4 was admitted as a swing bed patient on 9/2/11; diagnoses included repair of a fractured hip. The patient also had dementia, hypertension, and atrial fibrillation.

The patient was admitted for continued rehabilitation after a fractured hip, she had a history of a urinary tract infection, and on-going treatment for a calf wound.

The patient was prescribed antibiotics for urinary tract infection on 9/8/11, 9/21/11, 9/23/11, and 10/11/11. The recurrent urinary tract infections were not formally addressed in a plan of care with interventions that may have prevented further discomfort and infections.

An Admission Database/Initial Assessment was completed on 4/1/11. The assessment process lacked identification of potential problems, strengths and preferences.

The assessment process did not include causal or risk factors for decline or lack of improvement. The assessment process and data was not utilized to develop a plan of care that addressed the patient's care needs.

Based on clinical record review, the provider failed to prevent weight loss for one of (#1) of 4 sampled patients. Findings included:

Resident #1 was admitted as a swing bed patient on 2/27/12; diagnoses included resolving pneumonia and status post a fall at home. The patient was also diabetic, had a long history of smoking and COPD (chronic obstructive pulmonary disease), chronic back pain and depression.

The patient presented with nutritional risk factors that included difficulty swallowing, poor appetite, diabetes, and chronic pain. The patient's weight on admission (2/27/12) was 119.9 pounds. On 3/12/12 the patient's weight was 110 pounds.

The dietary services manager made a chart entry on 2/28/12 that acknowledged the patient's poor appetite and the need to encourage food and fluid intake, a full liquid diet, and pain. However, a nutritional assessment by a qualified dietitian to address the weight loss was not completed.