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Based on record review and interview, the facility failed to ensure updated and current Nursing Care Plans (NCP) for 8 of 12 (#4, #6, #7, #8, #9, #10, #11, #12) patients reviewed. Findings include:

Interview with the Director Accrediation, on 2/23/11 at approximately 1200, revealed that the facility Nursing Care Plans were documented on the "Active Problem List". The "Active Problem List: Chart Upon admission and each day" was documented on the forms. Review of patient NCP/ Active Problem Lists on 2/24/11 revealed that patients' #6, #7, #8, #9, #10,and #11did not have daily documentation.

Patients #6 and #7 were inpatients on the 8 South NeruoScience Progressive Care Unit. Patient #6 was admitted on 2/21/11 and was missing the 2/22/11 update. Patient #7 was admitted on 1/13/11 and was missing 2/23/11 update and 1/25/11 through 2/2/11 updates. Interview with Staff Nurse #L, on 2/24/11 at approximately 1100, revealed that nurses were to document on the Active Problem List every shift. Interview with Nurse Manager #Q verified that daily updates were missing on 2/24/11 at approximately 1115. The "Unit Routines- 8 South NeuroScience Progressive Care (NSPCU)" policy #164 dated 11/12/09, updated 2/2/11 documented "Problem list or clinical pathway reviewed, revised and updated every twenty-four (24) hours and PRN."

Patients #8 and #9 were inpatients on the 5 East Unit (SICU). Patient #8 was admitted on 2/8/11 and was missing documentation on 2/9/11, 2/10/11, 2/11/11, 2/13/11, 2/15/11, 2/16/11, 2/18/11, 2/19/11, and 2/20/11. Patient #9 was admitted on 2/12/11 and was missing 2/14/11, 2/19/11, 2/20/11, 2/21/11 and 2/22/11 daily updates. Interview with Nurse Manager #N, on 2/24/11 at approximately 1200, verified that daily updates were not documented. The "Unit Routines -5 East (SICU)" policy #161 issue date 7/8/10 documented "Plan of care reviewed and updated every 24 hours".

Patients #10 and #11 were inpatients on the 4 East Unit (MICU). Patient #10 was admitted on 2/8/11 and was missing daily updated NCP/ Active Problem List for 2/17/11 through 2/23/11. Patient #11 was admitted 2/15/11 and only had a NCP/ Active Problem List documented on 2/24/11. Interview with Nurse Manager #O, on 2/24/11 at approximately 1230, verified that daily documentation for NCPs/Active Problem Lists were missing. The "Unit Routines-4 East (MICU) policy #157 isssue date 9/8/10, documented "Plan of care reviewed and updated every 24 hours".


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Patient #4 was an inpatient on several units including: 4 East Unit (MICU), 5 East Unit (SICU)and 7 East Unit (Progressive step down). Patient #4 was admitted on 3/27/10 and was missing daily plan of care update documentation on 4/7/10, 4/10/10, 4/11/10, 4/12/10, 4/13/10, 4/14/10, 4/15/10, 4/16/10, 4/17/10, 4/25/10, 4/27/10, 4/29/10, 4/30/10, 5/1/10, 5/2/10, 5/8/10, 5/9/10, 5/10/10 and 5/11/10.
During review of policy titled, "Documentation Guidelines", it states, "Part II: Nursing Assessment and Plan of Care, Ongoing Assessments 2. A clinical assessment must be documented every 24 hours (every 12 hours in Critical Care...).
During an interview with staff F and H, on 2/23/11 at approximately 1400, verified that daily updates were not documented.

Patient #12 was an inpatient on 4 East (MICU) from the initial admission date of 2/4/11 thru 2/18/11 when the patient was transferred to the Medical Progressive Care Unit and remained there until the date of 2/24/11 when the patient was transferred back to MICU. During the patients entire length of stay from 2/4/11 thru 2/24/11 (date of survey) there was not one plan of care initiated for this patient.
During review of the policy titled, "Unit Routines-4 East (MICU)", it states, "A. Admission Documentation...f. Initiate plan of care and Patient Problem List", "B. Routine Documentation...a. Plan of care reviewed and updated every 24 hours".

During an interview with staff F and H on 2/24/11 at approximately 1000 these findings were confirmed.

Based on medical record review, interview and policy and procedure review, the facility failed to ensure the medical record contained information to describe the patient's progress and response to medications and services for 1 of 12 (#4) patients reviewed. Findings include:

During medical record review on 2/23/11 at approximately 1100 it was found that patient #4's chart failed to contain information regarding the patient's progress and response to treatment. Patient # 4 was admitted on 3/27/10 to the Surgical Intensive Care Unit (SICU), then on 4/18/10 the patient was transferred to the Medical Progressive Stepdown Unit. During this time frame on SICU the patient had no updated care plan from 4/9/10 thru 4/18/10. On 4/24/10 the patient was found unresponsive and the Rapid Response Team was called and the patient had to be intubated and Cardiopulmonary Resuscitation (CPR) had to be performed. The patient was then transferred to the Medical Intensive Care Unit (MICU), where the patient remained until 5/14/10 when he was admitted to hospice. During the time frame on the MICU of 4/24/10 thru 5/14/10 there was a significant lack of nursing progress notes in regards to the patients progress and response to treatments. From 4/19/10 thru 4/26/10 there was no nursing progress notes charted in the medical record, during which time frame the patient had been found unresponsive, intubated, and had to have CPR performed.

During review of the policy titled, "Documentation Guidelines for In-Patient Nursing", on 2/23/11 at approximately 1600, it states, "IV. Evaluation...1. The patient's plan of care will be identified daily by the RN. The RN will review the previous days' care plan and revise as appropriate to the updated needs of the patient. 2. The patient's response and progress towards meeting outcomes on all active problems will be documented. Assessment findings and interventions will be documented in the medical record. Documentation in the Progress Notes is required for problems that are worsening or not progressing".

During an interview on 2/24/11 at approximately 1115 with staff A, F, H and M all of which confirmed the above findings and lack of documentation. In addition, staff commented on the idea of charting by "exception". When staff M was questioned about what would be considered an "exception" to chart in a patients progress note she stated, "Any changes with patients condition, talking to doctor, phone calls in regards to patient, vent setting changes, changes in care plan..."

Based on observation, interview and record review, the facility failed to have complete restraint orders (type of restraint) for 4 of 5 patients (#8, #9, #10, #11) on restraints. Findings include:

Patient #8 was observed with bilateral wrist restraint and a mitt on her right hand. Record review realed that the physician had written an electronic order on 2/24/11, but had not specified what type of restraint to use. Patient #9 was observed with bilateral soft wrist restraints. Review of the medical record revealed that the patient had been on restraints since 2/12/11. Futher review of the hard copy and electronic records revealed that the patient had orders for restraints, but the orders failed to specify which restraints were to be used. Interview with the Nurse Manager #N and Clinical Infomatics Specialist #G verified that this documentation was lacking in the orders on 2/24/11 at approximately 1200.

Patients #10 and #11 were also observed with soft wrist restraints on in the 4 East Unit (MICU). Record review revealed that they were also lacking complete restraint orders in that the type of restraints were not specified. Interview with the Nurse Manger #O and Clinical Infomatics Specialilst #G, on 2/24/11 at 1230, verified that specific restraint types were not documented.

Based on record review and interview, the facility failed to provide a final diagnosis for 1 of 5 (#1) discharged medical records and failed to complete over 600 records within 30 days following discharge. Findings include:

Patient #1 expired on 7/5/08. Review of the patient's Discharge Summary dated 7/25/08 failed to specify a final diagnosis; "??????" was documented.

Interview with the Director of Medical Information Services on 2/24/11 at approximately 1400 revealed that the facility had over 600 incomplete charts delinquent over 30 days. Review of the data sheet for the previeous month revealed that there were 1,129 medical records that had not been completed within 30 days of discharge.