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Based on observation, record review and staff interviews, the Hospital failed to ensure that nursing staff developed individualized care plans with appropriate nursing interventions for 10 of 10 patient care plans reviewed. The intervention section in the 10 electronic care plans were blank.

Findings include:

Review of the Hospital's policy/procedure related to the plan of care indicated that a necessary component of a plan are nursing interventions. The Nursing Care Plan is to be initiated and developed from information obtain upon admission. The Nursing Care Plan is evaluated at least once per shift and revised as necessary.

1) Review of Patient #1's (Pt #1) medical record indicated that Pt #1 was admitted to the Hospital via the Emergency Department on 10/17/11 with left facial droop and slurred speech. Review of the standardized Nursing Care Plan dated 10/17/11, at 12:07 P.M. indicated that Patient #1's need for assistance from 2 staff members for transfer to a commode was not documented in Patient #1's Nursing Care Plan. The entire intervention section on the Nursing Care Plan was blank.

2) Review of Pt #2 and Pt #3's live electronic medical records via the Hospital's computer system on 11/10/11 at 1:30 P.M. with the Nurse Manager of Med/Surg Nursing indicated that Patient #2 had a standardized plan of care for a general medical/surgical patient and Patient #3's had a standardized plan for alteration in mental status, impaired gait and limited lower extremity strength. However, the Nursing Care Plan for each patient failed to include specific nursing interventions to address the above identified issues.

The Nurse Manager said that she did not see the specific nursing interventions in the Nursing Care Plans for Pt #2 and Pt #3 in the live electronic records.

3) Pt #4 was admitted to the Hospital on 10/19/1. On 10/21/11 Pt #4 fell at 9:00 A.M. Pt #4's Nursing Care Plan, dated 10/20/11, included alteration in mental status, impaired gait, potential for falls and was identified as a high risk for fall as problems. However, the Nursing Care Plan did not include nursing interventions specific to Pt #4's issues. Nursing documentation dated 10/21/11, indicated that Patient #4 fell onto his/her back while ambulating to the bathroom with the use of a walker. Pt #4 stated he/she stumbled because he/she attempted to step over the urinary drainage tube. However, review of Pt #4's plan indicated that the Nursing Care Plan was not updated after the fall.

4) Pt #5 was admitted to the hospital on 10/12/11 after tripping on a threshold while using her/his walker at the patient's assisted-living setting. Pt #5's Nursing Care Plan identified impaired mobility with the potential for injury. Pt #5's Nursing Care Plan did not identify interventions based on assessments performed.

5) Pt #6 was admitted to the Hospital on 10/6/11 for psychiatric care. Pt #6's Nursing Care Plan identified the patient's ineffective coping and the goals established to achieve effective coping skills. Pt #6's Nursing Care Plan did not identify specific nursing interventions to address how Pt #6 would attain effective coping skills.

6) Pt #7 was admitted to the Hospital on 9/27/11 with weakness and abdominal pain. Pt #7's Nursing Care Plan identified activity intolerance as a problem and identified a potential for falls. Pt #7's Nursing Care Plan did not identify nursing interventions to address the above issues. Documentation dated 9/29/11, indicated that Pt #7 was found sitting on her/his buttocks next to the bed in a puddle of urine and stool. Pt #7 reported he/she fell while getting out of bed. Pt #7's Nursing Care Plan was not revised after the fall.

7) Pt #8 was admitted to the Hospital on 9/14/11 for shortness of breath. Pt #8's Nursing Care Plan identified ineffective airway clearance, ineffective breathing pattern and activity intolerance. Documentation dated 9/15/11, indicated that Pt #8 was found on the floor with a hematoma on the back of his/her head. Pt #8's Nursing Care Plan did not identify specific nursing interventions to address the above issues.

8) Pt #9 was admitted to the Hospital on 8/28/11 with a partial small bowel obstruction. Pt #9's Nursing Care Plan identified pain and alteration in gastro-intestinal function as problems. Pt #9's Nursing Care Plan did not identify specific nursing interventions to address those problems identified upon assessment.

Documentation dated 8/30/11 indicated Pt #9 had a laparoscopic cholecystectomy. Documentation dated 8/31/11 indicated Pt #9 was found on the floor in the door way to the bathroom. Pt #9 reported falling while wearing slipper socks. Pt #9's Nursing Care Plan did not identify specific nursing interventions to address safety and fall precaution issues.

9) Pt #10 was admitted to the Hospital on 7/22/11 with seizure disorder versus pseudoseizures and depression with suicidal ideation. Pt #10's Nursing Care Plan identified anxiety, potential for injury and noncompliance as problems. What specifically Pt #10 was noncompliant with was not documented. Pt #10's Nursing Care Plan did not identify specific nursing interventions based on assessment performed to address the above issues.

Based on review of one of 10 sampled medical records, (Pt #1), the Hospital failed to ensure that the Hospitalist documented a post-fall evaluation after assessing Patient #1 who fell to her/his knees from a commode.

Findings include:

1) The Hospitalist who assessed Patient #1 was interviewed in person on 11/9/11 at 12:00 P.M. The Hospitalist said that Nurse #1 called to report the fall and he examined Patient #1. The Hospitalist said that Patient #1 denied pain and was able to move her/his legs with no restriction. The Hospitalist said that Patient #1 appeared calm and comfortable. The Hospitalist said that he did not write a progress note regarding his examination of Patient #1 after the fall.

2) Review of Patient #1's medical record confirmed there was no note written by the Hospitalist about the post-fall evaluation for Patient #1.