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Based on interview and record review the hospital failed to ensure 2 of 2 patients (Patient #2 and Patient #3's) nursing care plan were kept current. 1) (Patient #2's) care plan did not address the use of Plavix (blood thinner) and treatment for nausea, vomiting and diarrhea. 2) (Patient #3's) care plan did not address diabetes and a urinary tract infection.

Findings included:

1) (Patient #2's) initial nursing assessment dated 11/29/12 timed at 19:20 PM reflected, "Gastrointestinal positive for loose stools on admit...hemiparesis secondary to CVA (cerebrovascular accident)...short term goals will have no more than five anxiety attacks, will report decrease amounts of tearful episodes...provide therapy..."

The physician's orders dated 11/29/12 timed at 18:30 PM reflected, "Plavix (blood thinner) 75 mg (milligrams) po (by mouth) QD (every day)."

The MAR (medication administration records indicated (Patient #2) was administered Plavix from 11/30/12 through 12/07/12.

The physician's orders dated 12/01/12 reflected, "Phenergan 25 mg po every four hours times nausea and vomiting..." A second order was written 12/02/12 which reflected, "Phenergan 50 mg po or IM (intramuscular) for nausea and vomiting times twenty-four hours...clear liquid diet, imodium..."

The medication administration records indicated (Patient #2) was administered Phenergan 25 mg on 12/01/12 at 20:20 PM.

The 12/01/12 nursing progress note dated 12/01/12 timed at 20:50 PM reflected, "Complaints of having loose stool...at 23:30 PM...complains of nausea and vomiting..."

The interdisciplinary treatment plan dated 12/03/12 reflected no problem/intervention, short term/long term goals which addressed the administration of Plavix (blood thinner) and (Patient #2's) nausea, vomiting and diarrhea.

On 02/15/13 at approximately 01:05 PM Personnel #22 verified (Patient #2's) treatment/care plan did not include the administration/monitoring of Plavix and did not address (Patient #2's) nausea, vomiting and diarrhea.

2) (Patient #3's) initial nursing assessment dated 01/03/13 timed at 19:30 PM reflected, "Patient is confused...diabetes...sliding scale insulin..." The 72 hour initial nursing treatment plan attached to the above document reflected, "Problem safety, medication stabilization, altered sleep pattern...short term goals no harm to self/others...will sleep...interventions...fall precautions..."

The physician's orders dated 01/04/13 timed at 06:30 AM reflected, "Give glucagon IM (intramuscular) times one for low BS (blood sugar)."

The physician's orders dated 01/04/13 timed at 15:00 PM reflected, "FSBS (fasting blood sugar) AC (before meals) and HS (hour of sleep)...sliding scale..."

The physician's orders dated 01/08/13 timed at 15:00 PM reflected, "Bactrim DS (double strength) one po BID (twice daily) x (times) 5 days."

The medication administration records dated 01/04/13 through 01/18/13 reflected (Patient #3) was administered glucagon, blood sugar monitoring, insulin and was treated for a urinary tract infection.

The interdisciplinary individualized treatment plan dated 01/04/13 reflected, "Problem #1 aggression, potential to harm others..." The revised treatment plan dated 01/09/13 reflected, "Confused...no aggression..." The 01/11/13 revised treatment plan reflected, "Improving behavior..." The 01/16/13 revised treatment plan reflected, "Improving, anticipate discharge..." The above treatment plan did not address (Patient #3's) urinary tract infection and diabetes. No problems/intervention, short term/long term goals were addressed for the above problems.

On 02/15/13 at approximately 02:45 PM Personnel #22 was interviewed. Personnel #22 verified (Patient #3's) treatment/care plan did not address and/or include current medical problems. Personnel #22 stated the treatment for diabetes and a urinary tract infection was not addressed.

The hospital policy entitled, "Master Treatment Plan" with a revision date of 03/2012 reflected, "Each patient will have an individualized treatment plan...initial treatment plan will be initiated by the admitting nurse...and with the attending physician...the admitting nurse will complete problem/goal sheet for any Axis III diagnosis..."

Based on record review and interview, the hospital failed to complete medical records for three of three charts reviewed (Patients #18, #25, #26) whose History and Physical examination documentation was not signed by the attending physician within 30 days of discharge.

Findings included:

1) (Patient #18) was admitted on 12/31/12 and discharged on 01/02/13 with diagnoses including Mood Disorder and Oppositional Deficient Disorder.

(Patient #18's) History and Physical examination information was dictated on "01/01/12" at 06:08 AM and typed on "01/01/12" at 01:17 PM. The document was not signed by Personnel #37 as of 02/15/13.

2) (Patient #25) was admitted on 01/07/13 and discharged on 01/15/13 with diagnoses including Schizophrenia.

(Patient #25's) hand written History and Physical Examination document was not authenticated by a physician's signature, and not dated or timed.

3) (Patient #26') was admitted on 01/05/13 with diagnoses including Mood Disorder. The patient was discharged on 01/12/13 with the same diagnoses.

(Patient #26's) History and Physical Examination information was dictated on 01/05/13 at 07:42 PM and typed on 01/06/13 at 02:23 AM. Personnel #39 had not signed or dated the document as of 02/15/13.

During an interview on 02/15/13 at 10:40 AM, Personal #36 stated the expectation was that the physician signature was on the History and Physical document "as soon as it is in the chart."

Hospital Policy # 1000.18 dated 01/2013 reflected ...the transcribed report will be made available within 24 hours of patient admission and will be signed by the dictator."

Based on interview and record review the hospital failed to ensure 2 of 2 patients (Patient #2 and Patient #3's) treatment plans were kept current and addressed short and long term goals. 1) (Patient #2's) plan did not address the use of Plavix (blood thinner) and treatment for nausea, vomiting and diarrhea. 2) (Patient #3's) plan did not address diabetes and a urinary tract infection.

Findings included:

1) (Patient #2's) initial nursing assessment dated 11/29/12 timed at 19:20 PM reflected, "Gastrointestinal positive for loose stools on admit...hemiparesis secondary to CVA (cerebrovascular accident)...short term goals will have no more than five anxiety attacks, will report decrease amounts of tearful episodes...provide therapy..."

The physician's orders dated 11/29/12 timed at 18:30 PM reflected, "Plavix (blood thinner) 75 mg (milligrams) po (by mouth) QD (every day)."

The MAR (medication administration records indicated (Patient #2) was administered Plavix from 11/30/12 through 12/07/12.

The physician's orders dated 12/01/12 reflected, "Phenergan 25 mg po every four hours times nausea and vomiting..." A second order was written 12/02/12 which reflected, "Phenergan 50 mg po or IM (intramuscular) for nausea and vomiting times twenty-four hours...clear liquid diet, imodium..."

The medication administration records indicated (Patient #2) was administered Phenergan 25 mg on 12/01/12 at 20:20 PM.

The 12/01/12 nursing progress note dated 12/01/12 timed at 20:50 PM reflected, "Complaints of having loose stool...at 23:30 PM...complains of nausea and vomiting..."

The interdisciplinary treatment plan dated 12/03/12 reflected no problem/intervention, short term/long term goals which addressed the administration of Plavix (blood thinner) and (Patient #2's) nausea, vomiting and diarrhea.

On 02/15/13 at approximately 01:05 PM Personnel #22 verified (Patient #2's) treatment/care plan did not include the administration/monitoring of Plavix and did not address (Patient #2's) nausea, vomiting and diarrhea.

2) (Patient #3's) initial nursing assessment dated 01/03/13 timed at 19:30 PM reflected, "Patient is confused...diabetes...sliding scale insulin..." The 72 hour initial nursing treatment plan attached to the above document reflected, "Problem safety, medication stabilization, altered sleep pattern...short term goals no harm to self/others...will sleep...interventions...fall precautions..."

The physician's orders dated 01/04/13 timed at 06:30 AM reflected, "Give glucagon IM (intramuscular) times one for low BS (blood sugar)."

The physician's orders dated 01/04/13 timed at 15:00 PM reflected, "FSBS (fasting blood sugar) AC (before meals) and HS (hour of sleep)...sliding scale..."

The physician's orders dated 01/08/13 timed at 15:00 PM reflected, "Bactrim DS (double strength) one po BID (twice daily) x (times) 5 days."

The medication administration records dated 01/04/13 through 01/18/13 reflected (Patient #3) was administered glucagon, blood sugar monitoring, insulin and was treated for a urinary tract infection.

The interdisciplinary individualized treatment plan dated 01/04/13 reflected, "Problem #1 aggression, potential to harm others..." The revised treatment plan dated 01/09/13 reflected, "Confused...no aggression..." The 01/11/13 revised treatment plan reflected, "Improving behavior..." The 01/16/13 revised treatment plan reflected, "Improving, anticipate discharge..." The above treatment plan did not address (Patient #3's) urinary tract infection and diabetes. No problems/intervention, short term/long term goals were addressed for the above problems.

On 02/15/13 at approximately 02:45 PM Personnel #22 was interviewed. Personnel #22 verified (Patient #3's) treatment/care plan did not address and/or include current medical problems. Personnel #22 stated the treatment for diabetes and a urinary tract infection was not addressed.

The hospital policy entitled, "Master Treatment Plan" with a revision date of 03/2012 reflected, "Each patient will have an individualized treatment plan...initial treatment plan will be initiated by the admitting nurse...and with the attending physician...the admitting nurse will complete problem/goal sheet for any Axis III diagnosis..."