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Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure restraints were used in accordance with complete physician orders in 3 of 4 restrained patients (#1, #13, and #16) whose records were reviewed. This had the potential to interfere with coordination and safety of patient care. Findings include:

A hospital policy, "Restraints/Seclusion," last revised 2/09, stated restraint orders were to specify the reason for ordering restraints, the type of restraints, and the duration of restraints. All physician orders were to be documented in the paper medical record (as opposed to the electronic medical record).

The following patient records illustrate incomplete or potentially missing physician restraint orders.

1. Patient #1 was a 56 year old woman. Her medical records documented the following incomplete restraint orders:

a. An "Emergency Physician Record," dated 8/03/09, documented Patient #1 was brought to the ED by police due to agitation. An RN assessment note, dated 8/03/09 at 10:37 AM, documented Patient #1 was put in leather restraints (escorted by 3 police officers) due to extreme agitation and inability to control herself.

A physician's order documented on a form called "Violent Adult (Behavioral) Restraint Order," dated 8/03/09 at 10:05 AM, failed to indicate the type of restraints to be applied to Patient #1 or the reason for the restraints. The physician's order was incomplete. During an interview on 5/25/10 at 10:15 AM, ED RN #1 reviewed Patient #1's medical record and confirmed the physician's restraint order documentation was incomplete for the ED record on 8/03/09.

b. An "Emergency Physician Record," dated 1/03/10, indicated Patient #1 was brought again to the ED by police due to being "out of control." The Emergency Physician's Record," dated 1/03/10, documented the patient was angry, agitated, hostile, uncooperative, and abusive, with a clinical impression of psychosis and alcohol intoxication.

A signed, but undated and untimed, physician's order was documented on a form called "Violent Adult (Behavioral) Restraint Order." The order was for soft four point restraints. Failure to date and time the restraint order indicated an incomplete physician's order. During an interview on 5/25/10 at 9:40 AM, the Clinical Nurse Educator reviewed Patient #1's medical record and confirmed the physician restraint order documentation for 1/03/10 was incomplete.

2. Patient #13 was a 43 year old female who was transported via ambulance to the ED on 2/08/10. A physician's order for restraints, dated 2/08/10 at 11:00 PM, failed to describe the type of restraints to be applied or the clinical justification for the restraints. The physician's order was incomplete. An RN note, dated 2/08/10 at 11:00 AM, documented application of four point soft restraints for medical reasons. During an interview on 5/25/10 at 10:15 AM, ED RN #1 reviewed Patient #13's medical record and confirmed incomplete physician restraint order documentation.

3. Patient #16 was a 30 year old male who arrived at the ED on 12/11/09 via police escort. A physician's order for two point restraints, dated 12/11/09 at 7:30 PM, was documented on a form titled "Violent Adult (Behavioral) Restraint Order." The restraint order failed to include the specific type of restraint (whether soft or leather or other). It also failed to specify which limbs were to be restrained and the clinical justification for the restraints. A nursing note, dated 12/11/09 at 7:30 PM, documented police had handcuffed the patients arms to the bed and soft restraints had been applied to his legs. During an interview on 5/25/10 at 10:15 AM, ED RN #1 reviewed Patient #16's medical record and confirmed the physician's restraint order documentation was incomplete.

Orders for restraints were not complete.

Based on staff interview and review of patients' medical records and hospital policies, it was determined the hospital failed to ensure 2 of 2 behaviorally restrained patients (#1 and #16) who had police present in the room, were monitored by trained staff at intervals determined by hospital policy. This had the potential to interfere with quality and safety of patient care. Findings include:

A hospital policy, "Restraints/Seclusion," issued 7/05 and revised 2/09, stated patients in behavioral restraints were to receive one-to-one (continuous in person) monitoring (both visual and auditory observation) at all times. The monitoring was to be performed by an assigned staff member who was competent and trained in the use of restraints. The policy also stated trained staff were to monitor and evaluate patients at least every 15 minutes, and more frequently as needed. Monitoring was to include the following:

1. Nutrition and hydration status;
2. Circulation;
3. Range of motion;
4. Vital signs (exclusive of temperature);
5. Hygiene status;
6. Elimination needs;
7. Physical distress, status and comfort;
8. Current behavior and psychological status and comfort;
9. Signs of injury associated with restraint use;
10. Readiness for release from restraint.
The policy did not address the use of police officers as sitters.

During an interview on 5/25/10 at 10:15 AM, ED RN #1 stated police were used as sitters and they made "good babysitters." During an interview on 5/26/10 at 11:00 AM, the Vice President of Patient Care Services was interviewed. He stated he thought police could serve as sitters but acknowledged police were not hospital staff, their use as sitters was not addressed in the hospital's restraint policy, and that the hospital had not investigated or documented the specific training police had received in monitoring patients in restraints.

The following patient examples make three points: 1) The interval for monitoring, in some cases, exceeded the 15 minute minimum requirement stated in hospital policy. 2) Monitoring and/or documentation of monitoring failed to meet expectations stated in the hospital's restraint policy. 3) Police officers, who were not staff members and whose restraint training was not monitored by the hospital, were being used in the role of patient sitters.

1. Patient #1 was a 56 year old female who was restrained during 2 separate ED visits. Concerns related to the monitoring of Patient #1 while she was restrained include:

a. An "Emergency Physician Record," dated 8/03/09, indicated Patient #1 was brought to the ED by police due to agitation. An RN assessment note, dated 8/03/09 at 10:37 AM, documented Patient #1 was put in leather restraints upon arrival (escorted by 3 police officers) due to extreme agitation and inability to control herself.

The first documented RN assessment after the initial RN note, dated 8/03/09 at 11:27 AM, was 50 minutes after application of leather restraints (35 minutes beyond the minimum required time for restraint monitoring according to hospital policy). The RN note documented Patient #1 had good circulation, was able to move all her extremities, and remained combative and agitated with all attempts at care. There was no documentation to indicate Patient #1's vital signs were taken or nutritional, hydration or elimination needs were assessed or addressed.

An RN note, dated 8/03/09 at 11:50 AM, documented Patient #1 remained in restraints and that "Region 3 and family" were present at her bedside. There was no evidence of continuous patient monitoring by an assigned staff member who was competent and trained in the use of restraints.

During an interview on 5/26/10 at 10:50 AM, the Vice President of Patient Care Services reviewed Patient #1's record and confirmed ED documentation failed to show consistent monitoring of patients in restraints every 15 minutes according to hospital policy. He also confirmed the use of police (non-staff members) as sitters.

b. An "Emergency Physician Record," dated 1/03/10, indicated Patient #1 was brought to the ED by police due to being "out of control." The physician documented his clinical impression: psychosis and alcohol intoxication. An undated, untimed, "Violent Adult (Behavioral) Restraint Order" included an order for soft four point restraints. The clinical justifaction for restraints was "kicking and screaming."

An RN note, dated 1/03/10 at 10:25 PM, documented application of four point soft restraints. The note documented police officers participated in restraint application. An RN note, dated 1/03/10 at 11:00 AM documented RN monitoring of restraints. This was 35 minutes after application of restraints (20 minutes beyond the minimum required time for restraint monitoring according to hospital policy). The next documenation of restraint monitoring was at 11:30 PM on 1/03/10 and midnight on 1/04/10, both 30 minutes after the previous monitoring (15 minutes beyond the minimum required time for restraint monitoring). Restraints were removed at 12:45 AM on 1/04/10.

RN notes, dated 1/03/10 at 10:25 PM, 11:00 PM, through 1/04/10 at 12:45 AM indicated police officers were "sitters." There was no evidence of continuous monitoring by an assigned staff member who was competent and trained in the use of restraints.

During an interview on 5/26/10 at 10:50 AM, the Vice President of Patient Care Services reviewed Patient #1's record and confirmed ED documentation failed to show consistent monitoring of patients in restraints every 15 minutes according to hospital policy. He also confirmed the use of police officers to fulfill the requirement for sitters.

Hospital staff did not monitor Patient #1 while she was restrained consistent with hospital policy.

2. Patient #16 was a 30 year old male who arrived at the ED on 12/11/09 via police escort. A physician's order for two point restraints, dated 12/11/09 at 7:30 PM, was documented in the medical record on a form titled "Violent Adult (Behavioral) Restraint Order." The restraint order failed to include the specific type of restraint (whether soft or leather or other). It also failed to indicate which limbs were to be restrained or the clinical justification for the restraints. A nursing note, dated 12/11/09 at 7:30 PM documented police had handcuffed the patient's arms to the bed and soft restraints had been applied to his legs. During an interview on 5/25/10 at 10:15 AM, ED RN #1 reviewed Patient #16's medical record and confirmed incomplete restraint order documentation.

Monitoring of restraints for Patient #16 exceeded, at times, the 15 minute minimum requirement established by hospital policy. An RN note documented monitoring on 12/11/09 at 8:27 PM, followed by 8:58 PM, 31 minutes later, 9:05 AM, and then at 9:30 AM, 25 minutes later, again at 10:10 PM, 40 minutes later.

Several nursing notes, including 12/11/09 at 9:05 PM, 9:30 PM, 10:10 PM, 10:35 PM, documented "police" were present as Patient #16's sitter. There was no evidence of continuous monitoring by an assigned staff member who was competent and trained in the use of restraints.

The hospital failed to ensure monitoring of restrained patients at intervals expected in hospital policy. It also failed to monitor, or document monitoring, of patients for all aspects of monitoring required in hospital policy.

Based on staff interview and review of hospital personnel records, it was determined the hospital failed to document successful completion of hands-on restraint competencies for 4 of 6 ED RNs (#1, #2, #3, and #4) whose personnel records were reviewed for restraint competencies. This had the potential to result in restraints being completed by unqualified RNs. Findings include:

During an interview on 5/25/10 at 9:40 AM, the Clinical Nurse Educator in charge of restraint education stated hands on return-demonstration of restraint use was not part of the initial or annual restraint education that she provided for employees. She stated hands-on demonstration of restraint usage was a unit specific task at initial hire/orientation. She explained staff were expected to pass a written test to show knowledge regarding restraints. She stated that as long as she has been the Clinical Nurse Educator (since 2007) there had been no hands-on verification of restraint competencies during annual restraint education. She stated that RNs were expected to know how to apply restraints because it was taught in nursing school.

An Emergency Department Orientation Checklist (used for new hires) had one line dedicated to restraint competencies. The line read "able to care for patients in Behavioral and Medical restraints and adheres to the policies and procedures." This was a general statement and did not allow confirmation of specific hands-on restraint competencies, such as the demonstration of safe application and use of all types of restraints used in the hospital.

During an interview on 5/25/10 at 10:15 AM, ED RN #1 confirmed she was required to do a return demonstration in the ED upon initial orientation. Staff personnel records for ED RN #1 (doh 5/02/05), ED RN #2 (doh 4/07/08), ED RN #3 (doh 6/01/02), and ED RN #4 (doh 5/18/87) failed to document the successful demonstration of hands-on restraint competencies either upon orientation or since the initial hire date.

The hospital failed to ensure documentation in personnel records of all restraint competencies.

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure nursing staff supervised and evaluated the nursing care related to wound care and/or pain management for 3 of 6 medical/surgical patients (#14, #19, and 23), whose records were reviewed for wound and pain care. This resulted in the failure of nurses to respond to patients' needs. Findings include:

1. Patient #14's medical record documented a 75 year old female who was admitted to the hospital on 5/26/09 for placement of a suprapubic catheter and a pubovaginal sling. She was discharged home on 5/28/09.

A "PRE-OP ASSESSMENT," dated 5/26/09 at 1:18 PM, stated Patient #14 weighed 301 pounds and was 5 feet 0 inches tall. She had a left below the knee amputation. A progress note by the Wound Care Nurse, dated 5/27/09 at 1:45 PM, stated Patient #14 was unable to do any cares for herself. The note said Patient #14 was reluctant to be turned and only got out of bed at home with a Hoyer lift. The note documented skin breakdown in the skin folds of her abdomen, right buttock, and "other skin folds." The note stated it was a "Most challenging situation [due to] pressure, obesity & constant moisture."

The Director of the Medical/Surgical Unit was interviewed on 5/26/10 at 10:05 AM. She stated it was very difficult to turn Patient #14 and provide personal cares due to her obesity.

Patient #14's final "Patient's Care Plan," dated 5/26/09 and 5/27/09, stated "Integumentary...Potential/actual alteration in integumentary system related to disease process, aging, trauma and/or surgical procedures. ASSESSMENT: Integumentary-PROTOCOL: SKI INT." A specific plan to prevent skin break down and provide personal care and assistance with activities of daily living was not included in the POC.

The Wound Care Nurse documented evaluating and treating Patient #14 on 5/27/09 at 1:45 PM. She wrote wound care orders at that time including orders to turn Patient #14 every 2 hours and apply barrier creme and powders. Nursing notes did not document turning Patient #14 or other wound care prior to the Wound Care Nurse's visit. After the visit, repositioning Patient #14 was documented on 5/27/09 at 10 PM and on 5/28/09 at 12:05 AM, 4:00 AM, 8:25 AM, and 4:36 PM. No other notes documenting repositioning Patient #14 were documented.

The Director of the Medical/Surgical Unit was interviewed on 5/26/10 at 10:05 AM. She confirmed care to prevent skin breakdown was not consistently provided for Patient #14.

2. Patient #19's medical record documented a 78 year old female who was admitted to the hospital on 4/09/10 with diagnoses of acute and chronic kidney disease, cellulitis of her right toe, and diabetes type II. She was discharged on 4/13/10. The "PATIENT ASSESSMENT," dated 4/09/10 at 8:30 PM, stated the Patient #19 had cellulitis to mid-calf. The Assessment did not mention skin breakdown. A picture of Patient #19's buttocks on 4/11/10 at 12:30 AM, showed extensive excoriation of her buttocks and a 1/2 cm open area on her right buttock.

Patient #19's final "Patient's Care Plan," dated 4/09/10, 4/10/10, and 4/11/10, stated "Integumentary...Potential/actual alteration in integumentary system related to disease process, aging, trauma and/or surgical procedures. Integumentary status will be monitored."
A specific plan to prevent skin break down was not included in the POC.

Patient #19 was seen by the wound nurse at 1:10 PM on 4/12/10. A progress note and orders were written at that time for turning and protective cream.

The only nursing notes documenting repositioning Patient #19 and other interventions to prevent skin break down were written on 4/10/10 at 6:45 PM and on 4/11/10 between 12:00 noon and 2:30 PM. No other notes documenting the repositioning of Patient #19 were present.

The Director of the Medical/Surgical Unit was interviewed on 5/26/10 at 10:05 AM. She confirmed care to prevent skin breakdown was not consistently provided for Patient #19.



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3. Patient #23 was a 45 year old female who was admitted on 11/04/09 for a laparoscopic hysterectomy. According to the hospital's electronic documentation, on the patient assessment page of the Nursing Admission Assessment, dated 11/04/09 at 11:35 AM, Patient #23 indicated her pain goal was 3/10.

According to Patient #23's eMAR, she received 30 mg of Toradol (medication for pain) on 11/4/09 at 3:59 PM, however there was no documentation of Patient #23's pain level or characteristics of her pain. At the bottom of the eMAR was a reminder for RNs to, "Remember to Reassess." There was no evidence of re-assessment of Patient #23's pain after administration of Toradol.

In the hospital's patient assessment document, under the heading pain assessment, on 11/04/09 at 8:30 PM, documented Patient #23's pain level at 9/10. Within the same document, under the heading pain-response to intervention/note, was written, "Given 2 tablets of Norco (medication for pain)." A review of the hospital's eMAR confirmed the Norco was given at approximately that time and on that date. There was no evidence of re-assessment of Patient #23's pain after administration of Norco.

The next documentation of Patient #23's pain level (7/10) occurred on 11/04/09 at 11:24 PM. The record continued with, "Given Toradol. Headache subsiding from past Norco dose." The administration of Toradol was documented on the eMAR as Toradol 30 mg given at 11:22 PM. The time between assessments of Patient #23's pain was 2 hours and 54 minutes.

On 11/05/09 at 6:09 AM, the RN documented Patient #23's pain level at 8/10 with the additional note documenting that 2 tablets of Norco were given. There was no evidence of re-assessment of Patient #23's pain after administration of Norco. The time between pain assessments was 2 hours and 9 minutes.

On 11/05/09 at 8:38 AM, the RN documented Patient #23's pain level at 3/10 with the additional note documenting, "Toradol given." The time between this pain assessment and the previous pain assessment was 2 hours and 29 minutes. Again, Toradol was documented on Patient #23's eMAR as given 9:11 AM on 11/05/09, without assessment of Patient #23's pain level or its characteristics.

On 11/05/09 at 9:52 AM, the RN documented, "PT (patient) states the pain is feeling much better." There was no documentation of the patient's pain level.

On 6/2/10 at 10:55 AM, a phone interview was held with the Director of the Medical/Surgical Unit. She confirmed that there was no documentation of Patient #23's pain level or characteristics before the administration of the Toradol on 11/04/09 at 3:59 PM and again on 11/05/09 at 9:11 AM. She stated she was unsure that those fields were able to be documented.

4. A review of the hospital's comprehensive policy titled, "Pain Management Multidisciplinary Policy and Procedure," last revision 11/09, stated, "Assess characteristics of pain..."

The policy further stated, "A positive response to pain assessment, either verbal or non-verbal, requires intervention and reassessment following intervention. The patient's pain status is reassessed at least once a shift, 30 minutes to one hour after the pain relieving interventions or medication administration, and as needed." This was not done.

On 6/2/10 at 10:55 AM, a phone interview was held with the Director of the Medical/Surgical Unit. She confirmed that the hospital's policy for pain management was pain re-assessments to be done at least every shift, 30 minutes to one hour after pain medication was administered.

The hospital failed to follow its policy in reassessing the patient's pain level and characteristics following administration of medications.

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure nursing staff developed and kept current a nursing care plan for 6 of 7 medical/surgical patients (#14, #17, #18, #19, #20 and #23 ), whose records were reviewed for nursing POC. This resulted in a lack of direction to nursing staff caring for patients and had the potential to interfere with patient care. Findings include:

1. Patient #14's medical record documented a 75 year old female who was admitted to the hospital on 5/26/09 for placement of a suprapubic catheter and a pubovaginal sling. She was discharged home on 5/28/09.

A "PRE-OP ASSESSMENT," dated 5/26/09 at 1:18 PM, stated Patient #14 weighed 301 pounds and was 5 feet 0 inches tall. She had a left below the knee amputation. A progress note by the Wound Care Nurse, dated 5/27/09 at 1:45 PM, stated Patient #14 was unable to do any cares for herself. The note said Patient #14 was reluctant to be turned and only got out of bed at home with a Hoyer lift. The note said Patient #14 was reluctant to be turned. The note documented skin breakdown in the skin folds of her abdomen, right buttock, and "other skin folds." The note stated it was a "Most challenging situation [due to] pressure, obesity & constant moisture."

The Director of the Medical/Surgical Unit was interviewed on 5/26/10 at 10:05 AM. She stated it was very difficult to turn Patient #14 and provide personal cares due to her obesity.

Patient #14's final "Patient's Care Plan," dated 5/26/09 and 5/27/09, stated "Integumentary...Potential/actual alteration in integumentary system related to disease process, aging, trauma and/or surgical procedures. ASSESSMENT: Integumentary-PROTOCOL: SKI INT." A specific plan to prevent skin break down and provide personal care and assistance with activities of daily living was not included in the POC.

The Medical Records Technician was interviewed on 5/24/10 at 4:10 PM. She stated the medical record including the POC was complete.

The nursing POC did not address Patient #14's needs.

2. Patient #17's medical record documented a 71 year old male who was admitted to the hospital on 2/13/10 for generalized weakness following a fall. He was discharged on 2/15/10. The "PATIENT ASSESSMENT," dated 2/14/10 at midnight, stated Patient #17 was disoriented and forgetful and had weakness in all 4 extremities. The assessment stated he had a skin tear on his right elbow. The assessment stated he had a urinary catheter. A Nursing Shift Assessment, dated 2/14/10 at 9:00 AM, stated he was a high fall risk.

Patient #17's POC was not specific. For example, his POC stated "GU/Reproductive-Focused Assessment Potential/actual alteration in Genitourinary/reproductive system related to disease process, aging, surgical procedures, trauma, and/or pregnancy. The patient's GU&/or Reproductive function/status will be monitored, maintained/improved." Interventions included "ASSESSMENT: GU/Reproductive-PROTOCOL: SUP CAT *Discontinue of Foley Catheter *INTERVENTIONS: Genitourinary-PROTOCOL: SUP CAT." This was the most specific plan listed for Patient #17. It was not clear what the plan was directing staff to do. No attempts to discontinue Patient #17's catheter were documented. Catheter care was not documented during the patient's stay.

The Director of the Medical/Surgical Unit and the Supervisor of Case Management were interviewed together on 5/26/10 at 10:05 AM. They stated, if a nurse checked a box on a computer screen, that would lead to other boxes the nurse could check. They conceded specific interventions were not documented on the POC.

The nursing POC did not address Patient #17's needs.

3. Patient #19's medical record documented a 78 year old female who was admitted to the hospital on 4/09/10 with diagnoses of acute and chronic kidney disease, cellulitis of her right toe, and diabetes type II. She was discharged on 4/13/10. The "PATIENT ASSESSMENT," dated 4/09/10 at 8:30 PM, stated the Patient #19 had cellulitis to mid-calf. The Assessment did not mention skin breakdown. A picture of Patient #19's buttocks on 4/11/10 at 12:30 AM, showed extensive excoriation of her buttocks and a 1/2 cm open area on her right buttock.

Patient #19's final "Patient's Care Plan," dated 4/09/10, 4/10/10, and 4/11/10, stated "Integumentary...Potential/actual alteration in integumentary system related to disease process, aging, trauma and/or surgical procedures. Integumentary status will be monitored."
A specific plan to prevent skin break down was not included in the POC. Patient #19 was seen by the Wound Care Nurse at 1:10 PM on 4/12/10. A progress note and orders were written at that time for turning and protective cream. The nursing POC was not updated to include the Wound Care Nurse's recommendations.

The Vice President for Patient Care Services was interviewed on 5/26/10 at 1:45 PM. He stated the electronic medical record made personalization of POCs difficult. He stated the hospital was looking for systems that would allow greater specification of POCs.

The nursing POC did not address Patient #19's skin care needs.



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4. Patient #20's medical record documented an 86 year old female who was admitted to the hospital on 4/16/10 for altered mental status. She was discharged to an ALF on 4/21/10.

A "T-sheet" (a.k.a. triage sheet), used in the ED for physicians to document assessments of patients seen in the ED, dated 4/16/10 and signed, but not timed, checked off Patient #20's skin as warm and dry and intact. However, a nursing note, undated, untimed, documented Patient #20 as having had fragile skin issues and "alteration-unsure, duoderm on right hip. Patient arrived from ED with bandage." Further documentation of Patient #20's fragile skin condition was shown in the ALF's MAR with a physician order dated 3/15/10, for Baza skin barrier cream.

Patient #20's "Patient's Care Plan," dated 4/16/10, stated, "Integumentary...Potential/actual alteration in integumentary system related to disease process, aging, trauma and/or surgical procedures. ASSESSMENT: Integumentary-PROTOCOL: SKI INT."

Physician Orders, dated 4/17/10 at 11:30 AM, documented orders for an air mattress for skin issues and a wound care consult. There was no evidence that the air mattress or wound care was included in Patient #20's POC.

On 4/17/10 at 11:30 AM, the RN documented in the Patient Assessment, "Air overlay mattress for decub on RT (right) hip. Wound Care RN to see PT (patient) for wound on RT hip."

On 4/19/10 at 10:00 AM, the Wound Care Nurse documented in the hospital's Physician's Note paper document that Patient #20 had a stage II decubiti on the right coccyx. In addition, there was a signed order to turn Patient #20 every 2 hours, change dressings every Monday, Wednesday, and Friday, cleanse with wound cleanser, apply skin barrier, dress with foam, and to float her heels. There was no documentation that Patient #20's POC was updated to include the Wound Care Nurse's recommendations.

The Director of the Medical/Surgical Unit and the Supervisor for Case Management were interviewed together on 5/26/10 at 10:05 AM. They stated, if a nurse checked a box on a computer screen, that would lead to other boxes the nurse could check. They conceded patient specific interventions were not documented on the POC.

The nursing POC did not address Patient #20's specific skin care needs or include physician's skin care orders.

5. Patient #23's medical record documented a 45 year old female who was admitted to the hospital on 11/04/09 for a laparoscopic hysterectomy. She was discharged home on 11/05/09.

Patient #23's "Patient's Care Plan," dated 11/04/09, stated, "ASSESSMENT: Pain Management/Reassessment - PROTOCOL: PAI MGT." A specific plan to manage Patient #23's pain was not included in the POC.

The Director of the Medical/Surgical Unit and the Supervisor for Case Management were interviewed together on 5/26/10 at 10:05 AM. They stated, if a nurse checked a box on a computer screen, that would lead to other boxes the nurse could check. They conceded patient specific interventions were not documented on the POC.

The nursing POC did not address Patient #23's pain management needs.

6. Patient #18's medical record documented a 65 year old male who was admitted to the hospital on 2/12/10 for shortness of breath. He was discharged home on 2/15/10.

Patient 18's "Patient's Care Plan," dated 2/12/10, stated, "Respiratory Interventions..Respiratory problems related to disease process, trauma, or surgery. ASSESSMENT: RT: INTERVENTIONS-PROTOCOL: Res The." A specific plan to address Patient #18's breathing difficulties was not included in the POC.

In an interview with the Supervisor of Case Management on 5/26/10 at 11:17 AM, she confirmed the current documentation system has flaws and the hospital, "...has changed its system so that all services and assessments are done in the same system."

She produced further proof of change with the minutes of the Oversight Committee meeting minutes dated 2/25/10.

The nursing POC did not address Patient #18's specific respiratory needs.

7. The Director of the Medical/Surgical Unit, interviewed on 5/26/10 at 2:00 PM, stated the hospital did not have a policy specific to POCs. She provided surveyors with a policy titled "STANDARDS OF NURSING PRACTICE WITH ROLE DIFFERENTIATION," revised January 2006. The policy stated "The RN will: 4. Develop a plan of care...6. Revise the plan of care and/or expected outcomes as necessary to ensure progress towards desired outcomes." The policy did not provide direction as to how this would be done.

The Director of the Medical/Surgical Unit was interviewed on 6/02/10 at 11:00 AM. She provided surveyors with a training module titled "Plan of Care." The module was not dated. It explained the physical process of data entry for the POC but it did not discuss what type of information should be entered or how to individualize the POC so it was specific to the patient. The Director of the Medical/Surgical Unit stated a policy discussing the content of the medical record had not been developed.

The Vice President for Patient Care Services was interviewed on 5/26/10 at 1:45 PM. He stated the electronic medical record made personalization of POCs difficult. He stated the hospital was looking for systems that would allow greater specification of POCs.

The hospital failed to ensure the nursing staff developed and kept current nursing care plans for its patients.