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Based on interview and record review facility failed to develop and timely update a comprehensive person-centered nursing care plan for one patient (P-13) of twenty-one patients reviewed, resulting in nursing care plan not including specific patient treatment goals based on medical and psychological conditions, resulting in the potential for less than optimal outcomes. Findings include:

Review of electronic medical records for P-13 revealed that she was a 52- year-old female admitted to the facility on 7/12/23 via ambulance. Her chief complaint was a new wound to the abdomen that her homecare nurse found on assessment. P-13 also had diagnoses of pressure injury to the coccyx Stage II, morbid obesity, Atrial Fibrillation (on coagulation- Eliquis), Hypertension, Non-Stemi (Non-ST Segment Elevation Myocardial Infarction), COPD (Chronic obstructive pulmonary disease), on 5L of Oxygen at home, and CHF (Congestive heart failure).
On 7/12/23, upon work-up in the Emergency department, P-13 was found to have CHF exacerbation and concerns for multifocal pneumonia. For these reasons she was admitted by internal medicine for further evaluation and treatment.
According to nursing admission assessment notes, P-13 was non ambulatory, dependent for hygiene/peri-care, bed mobility and transfer. Foley catheter was in place. P-13's weight on admission was 317 kg (697 pounds). Patient was using BiPAP (is a form of non-invasive ventilation (NIV) therapy used to facilitate breathing) to aid with her breathing.

Physician's note dated 7/13/23 at 0310 indicated: Physical examination: patient does have ability to move her upper extremities. Bilateral chronic edema in both lower extremities. Patient reports that she has lymphedema in her right lower extremity. States that her extremity swelling is at baseline. Inspection reveals significant obesity. There are no focal areas of tenderness, except along the areas of bedsore. Along her left lateral abdomen there is a slight erythema and odor, but there's no pus or discharge at the site. Patient noted to have the skin breakdown along her left lateral abdomen, it appears to be Stage 2. Multiple small sores on her left stomach and thigh area. Large bruise on her left breast. I'm concerned that the patient's sores could be infected and will obtain multiple laboratory studies. My differential at this point includes but is not limited to acute bedsores, CHF exacerbation, and chronic A-fib (Atrial Fibrillation).
Emergency department nursing assessment note dated 7/13/23 had the following documented:" Patient alert and oriented x4. Pt has ulcers in her skin folds under her stomach. Wears 5L (liters) of oxygen via NC (nasal cannula)".

During P-13 stay in a facility she was consulted by endocrinology, cardiology, nephrology, urology, surgical services, wound care, psychiatry, gastroenterology (GI), Intensive Care services, OT/PT (occupational and physical therapy), RD (registered dietitian).

Review of nursing documentation revealed the following:
"Plan of Care Adult Medical:
1) Integumentary, Risk for injury. Goal-remains free from injury, initiated 7/14/23.
2) Safety. Risk for injury. Goal-remains free from injury, initiated 7/14/23.
3) Cardiovascular. Ineffective tissue perfusion. Goal- hemodynamic stability maintained, initiated 7/14/23.
4) Neuro/Cognitive/Perceptual, Chronic pain. Goal- pain improved/increase daily activity, initiated 8/7/23."

Further review of nursing notes and documentation did not indicate any nursing plans of care for P-13's oxygen therapy (patient used Oxygen and BiPAP) or anticoagulation therapy (patient was on Eliquis 5mg, by mouth twice a day), nutritional status or lower extremity edema.

Provider's note dated 8/10/23 had the following: "Anemia with hemoglobin reported 6.7, transfusion in progress (blood transfusion). She had variation of the hemoglobin for a period of time between 6.4 and 7.8, no Leukocytosis (high white blood cell count), platelets 154,000".
No updates for Care plans were made to address P-13's anemia and blood transfusion therapy.

There was a psychiatry note dated 8/1/23: "Chief complaint-" I've been feeling claustrophobic". This morning patient stated she had been experiencing anxiety when being turned by nursing staff to check/manage her wounds or cleaning. This is only occurring when she's turned to the side. She feels suffocated by her body habitus, which then triggers extreme anxiety, feeling that she cannot breathe and feeling very overwhelmed and panicky ".
No Care Plan updates by nursing was noted in P-13 medical record for anxiety.

P-13 had a chronic Foley catheter present on admission. It was exchanged by Urology on 7/25/23 at bedside. P-13 developed UTI (urinary trac infection) and later Sepsis. No Care Plan was initiated by nursing for catheter care, infection prevention and assessment, and/or antibiotic therapy.

On 8/16/23 P-13 was transitioned to Intensive Care Unit due to change in condition. Provider's note dated 8/16/23 had the following: Over the past several days the patient has been more hypotensive (low blood pressure) than usual, and her white blood cell count had been increasing. Patient's systolic blood pressure was found to be in 60s with increasing leukocytosis as well as acute kidney injury and recurrent hypoglycemia (low blood sugar). Empiric antibiotics were initiated by the medical team prior to consulting intensive care unit. Patient was transferred to the MICU (medical intensive care unit), at which time a right IJ CVC (Internal Jugular Central Venous Catheter) and a right arterial radial line were inserted. Patient was started on Levophed (drug similar to adrenaline, which is used to treat life-threatening low blood pressure) and given an additional 2-liter bolus. Patient was again found to be hypoglycemic despite the D50 administration, so a D5 drip was started. Patient is producing minimal urine per nursing report, there is a small amount of urine in the Foley bag, which is thick, dark, and gritty. Impression and Plan: Sepsis of unknown origin, probably complicated UTI, Atrial fibrillation, Leukocytosis (elevated white blood cells).
Review of nursing documentation for intensive care had the following Plan of Care:
1) Integumentary, Impaired tissue integrity. Goal- maintain/retain integrity of skin, initiated 8/16/23.
2) Cardiovascular. Ineffective cardiopulmonary tissue perfusion. Goal- hemodynamic stability maintained, initiated 8/16/23.
3) Respiratory. Impaired respiratory function. Goal- optimal gas exchange maintained, initiated on 8/18/23.
No other medical conditions, antibiotic therapy or central lines placements were addressed in P-13's nursing Plan of Care.

On 10/23/23 at 1110 during interview with Nurse Manager of the Intensive care units, Staff PP, she said that nurses complete their assessments every shift and document them in patients' medical records. All the changes in patients' conditions should be reflected in nursing plans of care. Nurses re-evaluate plan of care as needed.

On 10/24/23 at 0930 during interview with Nurse Manager of the medical surgical unit, Staff RR, she stated that nursing assessment is completed every shift and any changes in patients' condition should be reflected in nursing plan of care.

Facility's Policy for Nursing Plan of Care was requested and reviewed on 10/24/23. Policy effective 3/16/22 indicated:
"I. Objective.
To document the plan of care required to meet the admitted patient's needs.
IV. Policy
The RN develops, documents and updates the patient's Plan of Care, which includes problems and goals as identified through the episode of care.
V. Provisions
A. The Plan of Care is initiated with the patient and is documented within the first twelve hours of patient admission.
B. The RN integrates data obtained through objective and subjective means (e.g. Admission History and Assessments) to identify patient needs and care priorities.
C. The RN collaborates with the patient, family and/or significant other to formulate the Plan of Care.
D. The RN individualizes the pre-formatted plans of care to be reflective of the patient's condition.
E. The RN is responsible for reviewing, evaluating, and documenting the progress toward established plan of care goals and updates the plan of care accordingly, minimally every twelve hours. Documentation is reflective of findings from:
F. On-going and focused assessments plus additional updates to be completed to address new findings or
G. Change in the patient's condition (e.g., post-op, change in hemodynamic state, change in level of consciousness (LOC), invasive procedures).