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Based on observation, interview, record review and policy review, the facility failed to ensure that patients' nursing care plans were developed and kept current for seven patients (#6, #20, #8, #9, #11, #12, and #13) of 18 patients whose medical records were reviewed for nursing care plan goals and interventions. This had the potential to affect all patients by failing to ensure that the patients' physical and psychological needs were met. The facility census was 139 patients at the main campus and 64 patients at the other campus.

Findings included:

1. Record review of the facility's policy titled, "Care Planning Policy," reviewed 06/14, showed:
- The care plan is initiated within 24 hours of admission.
- The care plan is based on the assessment findings of the admitting nurse who will use the patient's diagnosis and problem list to develop a comprehensive, individualized patient-specific care plan that guides the patient care throughout the hospitalization.
- The care plan will include appropriate goals for the patient based on assessment/reassessment and involvement with patient and family.
- The care plan will utilize appropriate interventions to assist the patient with reaching the individualized goals.

2. Record review of Patient #6's medical record showed the following:
- Admission date of 09/23/14.
- Admission History and Physical (H&P) indicated that the patient's skin was negative for break down. H&P also includes history of Diabetes (inability to control sugar in blood stream-placing patients more at risk for skin breakdown).
- Nursing skin assessment on 09/24/14 at 2:00 AM showed a Left heel wound - hard and dry and Buttock wound described as deep & pink in coloration.
- The patient's nursing care plan did not include skin goals or interventions as related to the patient's skin break down.

During an interview on 10/06/14 at 4:05 PM, Staff J, Registered Nurse (RN) stated that there was not a nursing care plan for Patient #6's wound care and she stated that his care plan should have included wound care goals and interventions.

3. Record review of Patient #20's medical record showed:
- Admission date of 10/02/14.
-Admission H&P showed Assessment and Planning for Parkinson's (neurological [brain] disease with slowness of movement, shaking and problems with balance when walking) disease.
- The patient's nursing care plan did not include goals or interventions related to the patient's Parkinson's disease.

During an interview on 10/08/14 at 10:30 AM, Staff QQ, RN, stated that the care plan should contain goals and interventions related to the patient's Parkinson's disease diagnosis.

4. Record review of Patient #11, Patient #12, and Patient #13's care plans each showed a problem of potential for harm of self and others but staff failed to list interventions to prevent the problem.

During an interview on 10/07/14 at 10:55 AM, Staff T, Manager of In-patient Behavioral Health, confirmed the lack of interventions for Patient #13.

During an interview on 10/07/14 at 1:43 PM, Staff E, Quality Risk/Patient Safety for Behavioral Health, stated that by policy each problem in the care plan should have interventions listed.

During an interview on 10/07/14 at 2:30 PM, Staff FF, RN stated that he initiated Patient #12's care plan and failed to add interventions due to the shift being hectic with several admissions.

During an interview on 10/07/14 at 2:40 PM Staff Y, RN, stated that she initiated Patient #13's care plan and failed to add interventions because she thought the interventions were automatically added when the goals were placed in the care plan.

During an interview on 10/07/14 at 2:50 PM, Staff U, Clinical Support Nurse (CSN), stated that she thought the goals and interventions were the same and the interventions were automatically added when the problem goal was entered.

5. Record review of Patient #8's care plan showed a problem of Acute Psychosis (a disorder characterized by false ideas about what took place or who one was) but staff failed to add interventions to assist the patient to resolve the problem.

During an interview on 10/07/14 on 3:00 PM, Staff AA, RN, stated that she initiated Patient #8's care plan but failed to add interventions for the problem of Acute Psychosis because she thought the goals and interventions were the same.

6. Record review of Patient#9's care plan showed problems of depression (feeling worried or empty with a loss of interest in activities once enjoyed) and chemical dependency (addiction to a mood or mind-altering drug such as alcohol or cocaine) but failed to list interventions to assist the patient toward resolving these problems.

During an interview on 10/07/14 at 3:30 PM, Staff S, RN, stated that she initiated the care plan for Patient #9 and thought the goals and interventions were the same.

During an interview on 10/09/14 at 11:11 AM, Staff A, Chief Nursing Officer, stated that care plans should contain patient problems with goals and interventions.










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