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Based upon review of 4 (#7, #10, #11, #17) of 19 medical records and staff interview, the hospital failed to ensure the nursing staff kept current the nursing care plan for patients #7, #10, #11, and #17. Findings:

Review of patient #7's medical record revealed the patient was admitted to the hospital on 01/20/2014 with a diagnosis of burns to the right leg. Review of nursing care plans revealed plans for: Risk for Infection, Acute Pain, and Discharge Planning. During a physical tour of the hospital, on 01/27/14 at 2:30pm, patient #7 verbalized that during the night he had experienced an episode that resulted in the nursing staff placing him in a chair at the nursing station. Patient #7 was questioned if he had been confused; he replied if he was he did not know it. Patient #7 stated he was aware of his surroundings, his name, and just wanted the staff to call his daughter. Interviews, 01/28/14 at 9:22AM, with S24 Registered Nurse (RN), S16 RN and S2 RN, confirmed patient #7 had been confused on the night shift (7p-01/26/14 to 7a-01/27/14) and was observed leaving his room and walking toward the exit door. S16 RN further commented that patient #7 had been confused every morning when she talked with him. S16 RN further stated S6 Physician (patient #7) also stated that he was confused. Continued review of the nursing care plan revealed the RN failed to care plan patient #7 for confusion.

Review of patient #10's medical record revealed the patient was admitted to the hospital on 11/15/13 with the diagnoses of Altered Mental Status, Dehydration, Anemia, Dementia, Hypertension, and Anemia. Review of the plan of care revealed the Registered Nurse failed to identify nursing care needs related to the patient's anemia (which required the administration of blood products), hypertension, dementia and Atrial Fibrillation.

Review patient #11's medical record revealed the patient was admitted to the hospital on 12/11/13. The admission diagnoses included cellulitis and abcess of the trunk area and urinary tract infection. Review of the plan of care revealed the Registered Nurse (RN) failed to identify the open wounds present on the patient's trunk area and the urinary tract infection which required antibiotic therapy.

Review of patient #17's medical record revealed the patient was admitted to the hospital on 01/16/14 with the diagnosis of Altered Mental Status. Review of the nursing care plans revealed the RN had documented: Impaired Gas Exchange, Risk for Falls, Urinary and Bowel Incontinence, and Blood Administration, as the care plans. Interventions included monitoring patient #17's breathing, positioning, and manage environment for safety to avoid falls. Continued review of the nursing plan of care revealed the RN failed to identify nursing care needs related to the patient's altered mental status.