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Based on observation, staff interview, medical record review, and review of hospital policies and procedures, it was determined the hospital failed to ensure the necessary assessments, monitoring, and nursing measures were provided. The hospital failed to provide the necessary nursing supervision to ensure patients received the required nursing care (refer to A395). In addition, the hospital failed to develop and implement appropriate care plans (refer to A396). The cumulative effect of these systemic failures resulted in a determination that the facility failed to meet the Nursing Services Condition of Participation.

Based on staff interview, medical record review, and review of policies and procedures, the facility failed to ensure the sequential compression devices (SCDs) were applied and monitored according to the physician's orders for 1 of 2 sample patients (#3) identified at risk for development of a deep vein thrombosis (DVT). In addition, the facility lacked evidence nursing staff provided the necessary assessments, monitoring, and nursing measures to ensure adequate pain management for 4 (#2, #3, #9, #11) of 8 sample patients who had pain. The findings were:

In regard to SCDs:

Review of the 9/13/14 admission history and physical (H & P) showed patient #3 was admitted with complaints of abdominal pain. Admission diagnoses included cellulitis with an abscess. Review of physician's orders showed sequential compression devices (SCDs) were ordered on 9/13/14 with no order to remove them until they were discontinued by physician order. The following concerns were identified:
a. Observation on 9/17/14 at 9:30 AM along with RN #1 showed the patient was seated on the side of the bed without the SCDs in place. Interview with RN #1 and RN #2 at that time revealed the hospital policy was to leave SCDs on while in bed or up in a chair for more than 2 consecutive hours, otherwise they can be off and nurses follow that policy. However, review of the physician's orders did not indicate SCDs were to be applied according to hospital policy but as follows: "Place SCDs (Flowtrons) Until Discontinued [from] 9/13/14 [at] 1852 [6:52 PM) Until Specified." There was no physician order to have the SCDs off at any time or to implement them according to hospital policy.
b. Review of the nursing notes showed the SCDs were in place on 9/15/14 at 8:30 AM. However, review revealed all other nursing entries indicated the SCDs were off.
c. According to "Clinical Nursing Skills" by Smith, Duell and Martin, Seventh Edition, 2008, pages 1022 through 1024, evidence based nursing practice SCDs "...are used to reduce risk of developing deep vein thrombosis by improving blood flow through the leg veins. The wraps must be used continuously (unless ambulating) in order to be effective.

In regard to pain management:

1. Review of the 9/13/14 admission H & P showed patient #3 had complaints of abdominal pain. Review of the 9/13/14 timed at 1:27 PM laboratory report showed the patient had an elevated white blood cell count (WBC) of 19.0 (normal range is 3.2 to 9.9). Elevation in the WBC indicated infection. Review of the radiology report showed there was extensive inflammatory appearance/cellulitis involving the skin and subcutaneous tissue of the left lower quadrant abdominal wall. The physician ordered Percocet 5 mg/325 mg 1 tablet by mouth every 6 hours as needed for pain. The patient also had ibuprofen 600 mg 1 tablet by mouth every 6 hours as needed for pain ordered. Pain was identified as a problem on admission. The following concerns with pain management were identified:
a. Review of the care plan for pain showed there was no measurable goal; the goal was just "Patient's pain/discomfort is manageable." There was no evidence the patient had established an acceptable pain level. In addition, one of the interventions indicated non-pharmacological pain management interventions should be offered instead of, or with the administration of, medications. However, no non-pharmacological interventions were identified.
b. Review of the 9/15/14 nursing notes timed at 8:02 AM revealed the patient's pain level on a scale of 0 to 10 with 10 being the worst was 8 (8/10). The patient was administered pain medication but was not reassessed to determine the effectiveness of the medication in relieving his/her pain until 5:47 PM (9 hours after administration) at which time the pain level was identified as being 7/10. At 7:47 PM the patient's pain level was 9/10 but s/he declined a pain medication because a routine pain medication (Naproxen) had just been administered. However, no non-pharmacological interventions were offered or attempted in addition to the medication administered.
c. Review of the 9/14/14 nursing notes timed at 1 AM showed the patient's pain was 9/10. The patient received a medication for pain but was not reassessed for 3 and 1/2 hours (4:35 AM) to determine the effectiveness of the medication in relieving the pain.

2. Review of the 9/14/14 admission H & P showed patient #2 was admitted with a diagnosis of status asthmaticus (an asthma attack the does not respond to treatment with an asthma inhaler and is a medical emergency). Pain was identified as a problem for care planning. Medications ordered for pain included Norco 5 mg/325 mg 1 tablet every 6 hours as needed. The following concerns with pain management were identified:
a. Review of the care plan for pain showed there was no measurable goal; the goal was just "Patient's pain/discomfort is manageable." There was no evidence the patient had established an acceptable pain level. In addition, one of the interventions indicated non-pharmacological pain management interventions should be offered instead of, or with the administration of, medications. However, no non-pharmacological interventions were identified.
b. Review of the 9/15/14 nursing notes timed at 5:08 AM showed the patient had a pain level of 7/10 and was medicated. Continued review showed the patient's pain level was not reassessed again until 8:25 AM (3 and 1/2 hours later) at which time it was 6/10 and was described as continuous in nature. The next time the patient was assessed for pain was at 7:42 PM, another 11 hours. At that time the pain level was rated as 8/10.

3. Review of the physician's H & P showed patient #9 was admitted on 9/8/14 and diagnoses included gastrointestinal bleeding, chest pain and right knee pain. Review of the physician's progress notes, dated 9/13/14, 9/14/14, and 9/15/14 revealed the patient had acute and chronic knee pain due to degenerative joint disease. The daily 9/8/14 to 9/15/14 nursing care plans were reviewed. This review revealed pain management was identified as a problem and interventions included the following: "Assess and monitor patient's pain using appropriate pain scale. Collaborate with interdisciplinary team and initiate plan and interventions as ordered. Re-assess patient's pain level 30 - 60 minutes after pain management intervention". This review also showed one of the goals was to complete an additional reassessment within 2 hours of the intervention. Review of the physician's orders showed morphine (medication for pain) 4 milligrams was ordered on 9/8/14 to be administered for pain every two hours as needed. Review of the physician's orders showed Ultram (medication for pain) 50 milligrams was ordered on 9/12/14 to be administered every 6 hours as needed. Further review showed Percocet (medication for pain) was ordered on 9/14/14 to be administered every 6 hours as needed. The following concerns were identified:
a. Review of the 9/12/14 occupational therapy note showed therapy was not provided due to the patient's knee pain. Review of the 9/13/14 physical therapy note showed "...yelling and grimacing in pain when knee touched or near touched. Unable to attempt mobility today due to knee pain". Review of nursing documentation dated 9/10/14, 9/11/14, 9/12/14, and 9/13/14 revealed the patient had chronic and gradually worsening knee pain.
b. Review of the 9/11/14 nursing documentation showed the patient's acceptable pain level was 5, his/her pain level was 8 at 1:34 PM, and the patient received 4 milligrams of morphine. At 2:35 PM the pain level was 8, at 3 PM and 3:57 PM it was 7. The patient's pain level decreased to 5 at 5 PM (3 and one half hours after the medication was given). At 9:26 PM the pain level had increased to 8. Morphine was administered and the post pain assessment was not conducted until 1 and a half hours later. At that time the level was 4.
c. A review of the 9/10/14 to 9/14/14 documented pain assessments and interventions was conducted with the RN clinical analyst on 9/18/14 at 11 AM. According to the medication administration record morphine was administered 3 times on 9/10/14, 2 times on 9/11/14, 6 times on 9/12/14, 4 times on 913/14, and 2 times on 9/14/14. Review of the medication administration record showed Ultram was administered 2 times on 9/12/14, 9/13/14, and 9/14/14 and at no time on 9/15/14. This review also showed Percocet was administered 2 times on 9/14/14 and 3 times on 9/15/14. Review of 9/10/14 to 9/14/14 nursing documentation showed nurses did not consistently assess the effectiveness of pain medications after they were administered. This review also showed no systematic approach for determining which medications or combination of medications were most effective.
d. Review of the 9/10/14 to 9/14/14 nursing notes showed ice packs, emotional support, and repositioning were provided at various times. However, there was no evidence an assessment or evaluation had been completed to determine when these non-pharmacological interventions should be implemented or whether they were effective.

4. Review of the physician's H & P showed patient #11 was admitted on 9/12/14 and had chest pain and abdominal pain due to a liver and pelvic mass. The daily 9/12/14 to 9/15/14 nursing care plans were reviewed. This review revealed pain management was identified as a problem and interventions included the following: "Assess and monitor patient's pain using appropriate pain scale. Collaborate with interdisciplinary team and initiate plan and interventions as ordered. Re-assess patient's pain level 30 - 60 minutes after pain management intervention". This review also showed one of the goals was to complete an additional reassessment within 2 hours of the intervention. Review of the physician's orders showed Tylenol (for pain) 650 milligrams was ordered on 9/8/14 to be administered for pain every two hours as needed. The following concerns were identified:
a. A review of the 9/12/14 to 9/16/14 documented pain assessments and interventions was conducted with the RN clinical analyst on 9/18/14 at 11 AM. According to the medication administration record Tylenol was administered 2 times on 9/13/14, 3 times on 9/14/14, 2 times on 9/15/14, and 3 times on 9/16/14. Review of the nursing pain assessments dated 9/12/14, 9/13/14, 9/14/14, and 9/15/14 showed the patient had intermittent acute abdominal pain that was on-going. Further review showed nurses did not consistently complete an assessment for effectiveness after administering the Tylenol.
b. Review of the 9/15/14 and 9/16/14 nursing notes showed staff provided heat packs, emotional support, and distractions at various times in response to the patient's complaint of pain. However, there was no evidence an assessment or evaluation had been completed to determine when these non-pharmacological interventions should be implemented or whether they were effective.

5. Review of the hospital policy on pain management, revised August 2011, showed the following: "Reassess and document before and after each intervention or with any new complaint of pain.....Reassess pain relief, side effects, adverse effects and impact on patient function. Pharmacological interventions should be reassessed once sufficient time has elapsed to reach peak effect, typically 2 hours or less. ...Once a pain issue with a patient is identified, establish the patient's pain goal each day for what is maximum tolerable level of pain that will allow them to still be comfortable. Record in Interdisciplinary Plan of Care...If an acceptable pain level cannot be achieved with existing medical orders and nursing (or ancillary staff) interventions, notify the attending medical provider to obtain additional orders." Interview with RN #1 on 9/17/14 at 9:30 AM verified the hospital policy for reassessment of pain after pharmacological intervention was 2 hours or less.

Based on medical record review and staff interview, the hospital failed to ensure care plans were individualized, complete with measurable goals, updated when changes occurred and periodically evaluated for 7 of 11 sample patients (#1, #2, #3, #4, #7, #9, #12). The findings were:

1. Review of the 12/13/13 physician's note for patient #12 showed the patient had heart surgery on 12/7/13 and his/her post-operative condition included ventilator dependency due to respiratory failure, tube feedings, hemodialysis, antibiotic therapy, and sliding scale insulin injections. Review of the fluid intake and output records showed the patient also had an indwelling urinary catheter. Review of the care plans dated 12/6/13 and 12/13/13 showed interventions regarding nursing care for ventilator care, antibiotic therapy, dialysis, urinary catheter care, insulin injections, and glucose monitoring were lacking.

2. Review of the 9/9/14 and 9/10/14 nursing notes showed patient #9 required glucose monitoring for diabetes and nursing care for gastric bleeding. Review of 9/8/14 - 9/15/14 care plans showed they were developed daily and interventions that addressed glucose monitoring and gastric bleeding were lacking. Further review of the care plans showed pain was identified as a problem. Review of 9/10/14 to 9/14/14 nursing notes showed ice packs, emotional support, and repositioning were provided at various times for pain. Review of the care plans showed these modalities had not been included in the care plan. Further review revealed the lack of goals and a system for evaluating the effectiveness of the nursing interventions for pain and other problems that were identified.

3. Review of the 9/13/14 admission H & P showed patient #3 had diagnoses including cellulitis with abscess and abdominal pain. Review of the 9/15/14 physician progress notes timed at 11 AM revealed the patient's wound from the incision and drainage of the abscess was positive for MRSA (methicillin-resistant Staphylococcus aureus). The following concerns with care planning were identified:
a. Pain was identified as a problem to be addressed on the care plan. The physician ordered Percocet 5 mg/325 mg 1 tablet by mouth every 6 hours as needed for pain and ibuprofen 600 mg 1 tablet by mouth every 6 hours as needed for pain. However, review of the care plan for pain showed there was no measurable goal; the goal was "Patient's pain/discomfort is manageable." There was no evidence the patient had established an acceptable pain level. In addition, one of the interventions indicated non-pharmacological pain management interventions should be offered instead of, or with the administration of, medications. However, no non-pharmacological interventions were identified.
b. Review of the admission orders showed the patient was on contact isolation precautions. However, review of the care plan showed no evidence isolation was addressed.
c. Review of the 9/13/14 physician's orders showed sequential compression devices (SCDs) were ordered. Review of the care plan showed no evidence SCDs were addressed for deep vein thrombosis (DVT) prophylaxis.

4. Review of the 9/14/14 admission H & P showed patient #2 was admitted with a diagnosis of status asthmaticus (an asthma attack the does not respond to treatment with an asthma inhaler and is a medical emergency). The following concerns were identified:
a. Pain was identified as a problem for care planning. Medications ordered for pain included Norco 5 mg/325 mg 1 tablet every 6 hours as needed. Review of the care plan for pain showed there was no measurable goal; the goal was "Patient's pain/discomfort is manageable." There was no evidence the patient had established an acceptable pain level. In addition, one of the interventions indicated non-pharmacological pain management interventions should be offered instead of, or with the administration of, medications. However, no non-pharmacological interventions were identified.
b. Review of the admission orders showed the patient was on droplet isolation precautions. However, review of the care plan showed no evidence isolation was addressed.
c. Review of the care plan showed skin integrity was identified as a problem. The goal was "...Identify patients at risk for skin breakdown on admission and per policy. Collaborate with interdisciplinary team and initiate plans and interventions as needed." The goal was not individualized for this patient and no interventions were established. Furthermore, it was unclear if the patient had skin issues. An additional goal noted under the problem of skin integrity was "Nutritional status is improving...Collaborate with interdisciplinary team and initiate plan and interventions as ordered. Monitor patient's weight and dietary intake as ordered or per policy. Utilize nutrition screening tool and intervene per policy." Again, the goals were not individualized.
d. Urinary incontinence was identified as a problem upon admission. The goal written for this problem was "...Collaborate with interdisciplinary team and initiate plans and interventions as needed" which was identical to the goals written for skin integrity and nutrition. Again, the goal was not individualized and no individualized or specific interventions were identified. In addition, review of the nursing notes written after the patient was transferred out of the intensive care unit (ICU) showed the patient was continent. Interview with RN #1 and #2 on 9/17/14 at 9:30 AM revealed the patient was initially incontinent until s/he was stabilized in the ICU and was then continent. Both RNs verified the care plan should have been updated to reflect the patient's improved continence status.

5. Review of the 9/14/14 admission H & P showed patient #4 had diagnoses including lung cancer, diabetes mellitus type ll, atrial fibrillation, coronary artery disease (CAD), and hypertension. Active medical problems identified in the H & P included syncope and collapse, dehydration, hypotension, coronary artery disease, pulmonary embolism, and history of myocardial infarction. Admission orders included enteric isolation and to check orthostatic vital signs. Review of the care plan identified the following concerns:
a. Pain was identified as a problem with the goal being "Patient's pain/discomfort is manageable" but no acceptable pain level was established for the patient. Interventions included "Offer non-pharmacological pain mngmnt [management] interventions" but no interventions were noted. "Administer medications as ordered. Teach pt [patient] re: [regarding] med [medication] action, intended effects, side effects" but no specific instructions were established. "Report ineffective pain management to physician" but ineffective was not defined as to what level pain was acceptable for the patient. The last goal identified was "Other".
b. The remaining active problems identified including dehydration, syncope and collapse, diabetic monitoring, anti-coagulation therapy, and enteric isolation were not addressed in the care plan.

6. Review of the 9/15/14 admission H & P showed patient #1 had diagnoses including shortness of breath with a history of COPD (chronic obstructive pulmonary disease), CAD and acute hypoxia (not enough oxygen). Other diagnoses included hypertension, renal disorder, asthma, and stroke. Active medical problems identified were acute respiratory failure, acute bronchitis, and CAD. Admission orders included placing the patient on a BiPAP machine (Type of continuous positive airway pressure in which both inspiratory and expiratory pressures are set above atmospheric levels which assists a patient with sleep apnea, congestive heart failure, and other forms of respiratory insufficiency), droplet precautions, and SCDs for DVT prevention. Review of the care plan showed the following concerns:
a. Pain was identified as a problem upon admission. Review of the care plan showed it was identical to the pain care plan written for patient #4. There were no measurable goals or individualized interventions.
b. Review showed droplet isolation precautions were not addressed in the care plan and neither was the utilization of the BiPAP machine or the SCDs.

7. Review of the medical record showed patient #7 had diagnoses including septicemia, pneumonia, acute respiratory failure, malignant neoplasm of the esophagus, atrial fibrillation, malnutrition, osteoarthritis and hypertension. Active medical problems identified in the 5/25/14 admission H & P included: atrial fibrillation, chronic tophaceous (porous stone) gout, osteoarthritis, hypertension, esophageal cancer, chronic lower leg DVT, pneumonia, and congestive heart failure. Review of the care plan showed the following concerns:
a. Pain was identified as a problem with the goal being "Patient's pain/discomfort is manageable" which was not measurable as no acceptable pain level was established by the patient. The only intervention written was "Assess and monitor patient's pain using appropriate pain scale. Collaborate with interdisciplinary team and initiate plan and interventions as ordered. Re-assess patient's pain level 30 -60 minutes after pain management intervention." No individualized interventions were established or implemented.
b. Review of the nursing notes throughout the patient's hospitalization indicated s/he had constant diarrhea and was frequently unable to reach the toilet in time to prevent soiling him/herself. However, review of the care plan showed good hygiene and the patient's continual diarrhea were not addressed. Interview with RN #1 on 9/17/14 at 9:30 AM revealed the patient was in the active dying process and was "oozing" diarrhea almost continually which made it difficult to keep the patient clean. In addition, the patient's active dying process and spiritual needs were not addressed in the care plan.

8. Interview with RN #1 on 9/17/14 and RN #2 at 9:30 AM revealed the hospital was in the process of revising the care planning process in order to attempt to make the care plans more individualized. Both RNs further acknowledged the current care plans were not individualized and goals were not measurable.

9. According to Elsevier's 2009 Mosby's medical Dictionary, Eighth Edition, "A patient plan of care is a document developed after the patient assessment that identifies the nursing diagnoses to be addressed in the hospital or clinic. The plan of care includes the objectives, nursing interventions, and time frames for accomplishment and evaluation. It should be formulated with input from the patient and the patient's family".

10. Review of Smith, Duell, and Martin, "Clinical Nursing Skills," Seventh Edition, 2012, Chapter 3, "Managing Client Care" showed, "...care plans are an integral part of providing nursing care. Without them, quality and consistency of client care may not be obtained."