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Based on medical record reviews, facility policy/procedure reviews and staff interviews, the facility failed to ensure that a less restrictive intervention was considered prior to restraint use (A165), failed to ensure care plans were updated to include restraint use (A166), failed to ensure orders were obtained for restraint use (A168) and restraint use was monitored per facility policy (A175). The cumulative effect of these systemic practices resulted in a risk to the health and safety of all patient in need of restraints.

Based on review of medical records and facility policy/procedures and staff interviews, the facility failed to ensure care was provided per physician's orders and nursing plan of care for all patients(A395) and care plans were initiated upon admission and updated with any changes (A396). The cumulative effect of these systemic practices resulted in the facility's inability to ensure the patient's nursing needs would be met.

Based on medical record reviews and staff interview, the facility failed to ensure a less restrictive intervention was used or considered prior to the use of restraints for one of three patients reviewed who have restraints (Patient 12). A total of ten medical records were reviewed. The current census was 67.

Findings include:

The medical record for Patient 12 was reviewed on 05/13/13. An initial order dated 03/30/13 at 1:45 AM for bilateral wrist restraints was noted after Patient 12 pulled out his/her feeding tube. Patient 12 was noted to be in restraints (bilateral wrist, freedom splint and/or a mitt) from the time of the initial order on 03/30/13 until 05/08/13, approximately 44 days. The registered nurse's (RN) restraint documentation at 2:00 AM on 03/30/13 noted alternatives attempted included "increased observation, increased reasoning and adjusted environment."

On 05/15/13 at 9:56 AM Staff A was asked to explain what increased observation means and he/she stated typically a patient is moved to a high observation room or a room where a nurse is always stationed inside the room. Sometimes the patient will have a sitter. Staff A was then asked what type of room Patient 12 was in at the time of admission and whether or not he/she changed rooms since then. Staff A was also asked if at any time Patient 12 had a sitter. At 10:02 AM Staff A confirmed Patient 12 was in a private room from the time of admission on 03/22/13 until 04/12/13, approximately 13 days after the initial order for restraints was written. Staff A also confirmed there was no documented evidence that staff adjusted the environment or increased observation of Patient 12 prior to placing him/her in restraints. Staff A stated Patient 12 had a sitter "off and on" since admission but there was no documented evidence that Patient 12 had a sitter.

These findings substantiate the allegations contained in Substantial Allegation OH00069715.

Based on medical record review, policy review, and staff interview the facility failed to ensure care plans were updated to include restraints for two of the three patients reviewed who had restraints (Patients 1 and 12). A total of ten medial records were reviewed. The facility had a census of 67.

Findings include:

The medical record for Patient 1 was reviewed on 05/13/13. The patient had an initial restraint order dated 05/08/13 at 12:00 AM. The medical record documented a verbal order was obtained for a left mitt restraint that was applied on 05/07/13 at 7:28 PM to prevent the patient from pulling at his/her tubes. As of 2:47 PM on 05/13/13, there was no documentation on the patients care plan lacked that addressed restraint use and interventions. This finding was verified by Staff A.

The medical record for Patient 12 was reviewed on 05/13/13. Patient 12 had an initial order for bilateral wrist restraints dated 03/30/13 at 1:45 AM. A nursing note indicated the restraints were applied at 2:00 AM on 03/30/13. As of 10:02 AM on 05/15/13, the patients care plan had not been updated to reflect the use of restraints. Staff B confirmed this finding.

The "Use of Physical Restraint for Medical Non-Violent, Non-Self Destructive Behavior" policy was reviewed on 05/13/13. The policy stated the care plan is to include the safety issue that resulted in the need for restraints, measurable outcome-oriented goals, interventions to minimize restraint use, alternatives tried to end restraint use, on-going evaluation of the restraints, and patient/family education regarding restraints.


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These findings substantiate the allegations contained in Substantial Allegation OH00069715.

Based on medical record review, policy review, and staff interview the facility failed to ensure orders were obtained for all restraints per the facility's policy for three of three patients who had restraints. (Patients 1, 2, and 12). A total of ten medical records were reviewed. The facility had a census of 67.

Findings include:

Review of the facility's policy "The Use of Physical Restraint for Medical Non-Violent, Non-Self Destructive Behavior" was reviewed on 05/13/13. The policy stated an order for a restraint must be obtained immediately (within a few minutes) of applying the restraint unless an order was obtained prior to placement. The medical staff must reevaluate the need for restraints and order the renewal of all restraints each calendar day. The medical record reviews for Patients 1, 2, and 12, revealed non-compliance with the facility's policy as follows:

1. The medical record for Patient 1 was reviewed on 05/13/13. The medical record documented a verbal order was obtained for a left mitt restraint and was applied on 05/07/13 at 7:28 PM to prevent the patient from pulling at his/her tubes. The patient had an initial restraint order dated 05/08/13 at 12:00 AM, but the verbal order for restraint placement at 7:28 PM on 05/07/13 was not found in the medical record. Review of the facility's documentation on the 24 Hour Restraint Order and Flow Sheet Documentation form listed the practitioner assessment of Patient 1's need for restraint as "other" on 05/08/13, 05/11/13, 05/12/13, and 05/13/13; in addition, on 05/10/13 this area was left blank. The medical record lacked documentation by the physician reordering the restraints that a reassessment was completed. This finding was verified by Staff A.

2. The medical record for Patient 2 was reviewed on 05/14/13. The medical record documented bilateral soft wrist restraints were applied on 04/24/13 at 9:43 PM and were in place without interruption through 05/10/13 at 8:00 AM. Review of the 24 Hour Restraint Order and Flow Sheet Documentation form listed the practitioner assessment of the patient's need for restraint as "other" on 05/08/13; in addition, on 04/26/13 this area was left blank. The medical record lacked documentation by the physician re-ordering the restraints that a reassessment was completed. The 24 Hour Restraint Order and Flow Sheet Documentation for 04/24/13 at 9:43 PM noted a verbal order was obtained; however as of 05/16/13 at 11:00 AM, this order was still not signed by the physician. This finding was verified at 11:30 AM on 05/14/13 by Staff A.

3. The medical record for Patient 12 was reviewed on 05/13/13. Patient 12 had an initial order for bilateral wrist restraints dated 03/30/13 at 1:45 AM. A nursing note indicated the restraints were applied at 2:00 AM on 03/30/13 after Patient 12 was discovered in his/her room with the feeding tube in hand. Restraint orders for Patient 12 were reviewed for the period of time 03/30/13 - 05/08/13.

On 05/16/13 at 8:50 AM Staff A and B were asked to provide the physician progress notes that corresponded to the continued use of restraint orders for Patient 12. At 9:28 AM, Staff A and B returned and stated there was no documented assessment of Patient 12 or physician progress notes for the initiation of the restraints on 03/30/13. Staff A confirmed that 10 of 41 orders for the restraints for Patient 12 did not have a documented assessment or progress note by a physician indicating the need for continued use. Staff A also confirmed there was no order for restraint use on 04/01/13 or 05/03/13 despite documented evidence that Patient 12 was in bilateral wrist restraints on both days.


Staff A was interviewed on 05/16/13 at 11:00 AM. Staff A stated if the physician checked the "other" box on the 24 Hour Restraint Order and Flow Sheet Documentation form there should be an accompanying physician progress note noting that assessment. If the box stating "I have completed a comprehensive individual assessment..." was checked then an additional note by the physician was not necessary. Staff A stated that all the restraint orders will be renewed at midnight as they were only good for one calendar day per the facility's policy. Staff A stated the policy for signing verbal orders refers to the Medical Staff Rules and Regulations for the time frame, but the rule and regulations do not specify what that time frame was.

The General Documentation Guidelines policy was reviewed on 05/16/13. The policy stated verbal and telephone orders must be authenticated by the responsible practitioner within the time frame defined in the Medical Staff Rules and Regulations. The Medical Staff Rules and Regulations was reviewed on 05/16/13, and stated the verbal orders were to be authenticated within the time frame specified in state law.

These findings substantiate the allegations contained in Substantial Allegation OH00069715.

Based on medical record review, policy review, and staff interview the facility failed to ensure restraint use was monitored per facility policy for two of three patients reviewed of patients who required restraint use (Patients 1 and 2). A total of ten medical records were reviewed. The facility had a census of 67.

Findings include:

The medical record for Patient 1 was reviewed on 05/13/13. The patient had a left mitt restraint applied on 05/07/13 at 7:28 PM to prevent the patient from pulling at his/her tubes. The restraint remained on the patient through 05/13/13. The medical record lacked documentation of restraint safety checks at least every two hours on 05/12/13 from 12:50 AM through 7:00 AM and from 3:47 PM through 6:03 PM. This finding was verified by Staff A at 2:47 PM on 05/13/13.

The medical record for Patient 2 was reviewed on 05/14/13. The medical record documented bilateral soft wrist restraints were applied on 04/24/13 at 9:43 PM and remained on the patient through 05/10/13 at 8:00 AM. The medical record lacked documentation of restraint safety checks at least every two hours on 04/26/13, 04/29/13, 05/01/13, 05/02/13, 05/03/13, and 05/08/13. This finding was verified at 11:30 AM on 05/14/13 by Staff A.

The "Use of Physical Restraint for Medical Non-Violent, Non-Self Destructive Behavior" policy was reviewed on 05/13/13. The policy stated observations must be documented every two hours including restraint status, proper placement, range of motion/ambulation, position, fluid/nourishment, toileting, personal hygiene, level of consciousness, orientation, emotion, behavior observed, and response to the restraint. In addition the continuation or discontinuation decision will be documented.

These findings substantiate the allegations contained in substantial allegation OH00069715.

Based on medical record review, policy review, and staff interview the facility failed to ensure care was provided per physician's orders and nursing care interventions were identified for all patients. This affected ten of ten medical records reviewed (Patients 1, 2, 3, 4, 5, 6, 7, 8, 11, and 12). The facility had a census of 67.

Findings include:

1. The medical record for Patient 1 was reviewed on 05/13/13. The patient was admitted on 05/07/13 at 6:27 PM with a diagnosis of stroke and malnutrition. The patient had continuous tube feeding, was bed bound, had left sided weakness, a flaccid right side, and had an indwelling urinary catheter. The medical record lacked documentation the patient was turned and repositioned every two hours to prevent skin breakdown on 05/07/13 through 05/12/13. Review of the "Pressure Ulcer Prevention and Treatment" policy on 05/15/13, stated that patients with a Braden score (scale for predicting pressure sore risk) for moderate or high risk should be turned and repositioned a minimum of every two hours. A Braden score less than nine indicated severe risk. A Braden score of 10-12 indicated high risk. A Braden score of 13-14 indicated moderate risk. A Braden score of 15-18 indicated low risk.
Patient 1's Braden scores fluctuated between eight and fifteen on these dates.

According to the medical record Patient 1 was receiving tube feeding per feeding tube at 50 milliliters (ml) per hour. The patient's intake and output documentation did not include the tube feedings received every 12 hours from 05/07/13 through 05/13/13, and no output was documented. Review of the facility's policy for the "Documentation of Food and Fluid Intake" stated it was the facility's policy to document food and fluid intake on all patients to screen for inadequate nutrient intake.

Further review of the medical record contained once daily documentation of mouth/oral care from 05/07/13 through 05/13/13. Review of the facility's policy for "Oral Hygiene" on 05/15/13, stated that patients will receive oral hygiene at a minimum of twice a day to provide comfort and reduce the risk of infection. The policy also stated that patients who were unconscious, unable to take fluids by mouth, receive oxygen, have elevated temperatures, were vomiting, and have feeding tubes will be assessed for oral hygiene needs and have individualized care planning for frequency of oral hygiene.

This finding was verified by Staff A at 2:47 PM on 05/13/13.

2. The medical record for Patient 2 was reviewed on 05/14/13. The patient was admitted on 04/23/13 at 6:25 PM with diagnoses of acute/chronic respiratory failure, chronic renal failure, and sepsis. The patient had a tracheostomy, was on a ventilator, had a pressure ulcer on admission, had an indwelling urinary catheter, and had continuous tube feeding. The medical record contained orders dated 04/23/13 for tube feeding per feeding tube at 30 ml per hour, turning and repositioning every two hours, intake and output (I and O) at 12 and 24 hours. On 04/24/13 the tube feeding was increased to 40 ml per hour.

The medical record lacked documentation Patient 2 was turned and repositioned at least every two hours from 04/24/13 through 05/14/13. The patient's Braden scores fluctuated from 11 to 17 on these dates. There was documentation that Patient 2 acquired a pressure ulcer to the left buttock on 05/14/13 measuring 5.5 centimeters by 6 centimeters, by 0.1 centimeters and was a stage two wound.

Further review of the medical record revealed that Patient 2's I and O documentation did not include documentation of tube feedings received every 12 hours from 04/23/13 through 05/14/13 and the output was recorded less frequently than daily. There was also no documentation that respiratory therapy documented of oral care was completed on 04/23/13, 04/24/13, and 04/25/13 and by nursing on 04/23/13, 04/24/13, 04/26/13, 04/30/13, 05/01/13, 05/02/13, 05/05/13, 05/06/13, and 05/10/13. The medical record contained documentation of once daily oral care by nursing the remaining days.

This was verified at 11:30 AM on 05/14/13 by Staff A.

3. The medical record for Patient 3 was reviewed on 05/14/13. The patient was admitted on 04/24/12 with a diagnoses of respiratory failure, seizure disorder, and stroke. The medical record was reviewed for the date range of 05/07/13 through 05/14/13. The patient had a continuous tube feed, was on a ventilator, had a tracheostomy, and received dialysis. The patient had orders for turning and repositioning every two hours.

Further review of the medical record revealed there was no documentation Patient 3 was turned and repositioned at least every two hours 05/07/13 through 05/14/13. The patient's Braden scores fluctuated from 10 to 13 during this time frame. The patient's I and O record did not include documentation of the tube feedings twice a day on 05/09/13, 05/11/13, and 05/13/13; and lacked consistent documentation of output more frequently than daily.

This finding was verified by Staff A on 05/14/13 at 11:30 AM.

4. The medical record for Patient 4 was reviewed on 05/14/13. The patient was admitted on 05/10/13 at 6:58 PM with diagnoses of respiratory failure, delirium, and encephalopathy. The patient was receiving continuous tube feeding. Review of the medical record revealed there was no documentation Patient 4 was turned and repositioned at least every two hours on 05/10/13, 05/11/13, 05/13/13, and 05/14/13. The patient's Braden score fluctuated from 12 to 14 during these dates with the first Braden score recorded on 05/11/13. The patient's I and O record did not include documentation of the tube feedings received twice a day on 05/13/13 and 05/14/13; and lacked consistent documentation of output more frequently than daily. The medical record lacked documentation oral care was provided more than once a day during this time frame.

This finding was verified by Staff A on 05/14/13 at 4:00 PM.

5. The medical record for Patient 5 was reviewed on 05/15/13. The patient was admitted on 05/09/13 at 11:40 AM with diagnoses of cervical adenocarcinoma, an abdominal wound, and deconditioning. The patient had a colostomy, ileostomy, and an indwelling urinary catheter. The medical record contained orders dated 05/10/13 for I and O monitoring at 12 and 24 hours and turning and repositioning every two hours. The medical record did not have documentation Patient 5 was turned and repositioned at least every two hours on 05/09/13, 05/10/13, 05/12/13, 05/13/13, 05/14/13, and 05/15/13. The I and O documentation did not include the intake for all three meals on 05/09/13, 05/10/13, 05/11/13, and 05/13/13 and the output was inconsistently documented for each staff shift. The medical record also lacked documentation oral care was provided twice a day.

This finding was verified by Staff A on 05/15/13 at 10:30 AM.

6. The medical record for Patient 6 was reviewed on 05/15/13. The patient was admitted on 05/09/13 at 10:58 AM with diagnoses of stroke, pneumonia, and meningitis. The patient was receiving continuous tube feedings until 05/10/13 at 1:07 PM. and had an indwelling urinary catheter. The medical record lacked documentation Patient 6 was turned and repositioned at least every two hours from 05/09/13 through 05/15/15, even though this intervention was added to the patient's care plan on 05/10/13. The patient's Braden scores fluctuated from 11 to 16 during this time frame. The patient's I and O record did not have documentation of three meals per day from 05/10/13 through 05/13/13. The patient's output lacked documentation on every staff shift of urinary output and lacked documentation of any bowel movements. The medical record did not have documentation that oral care was provided twice a day.

This finding was verified by Staff B on 05/15/13 at 11:30 AM.

7. The medical record for Patient 7 was reviewed on 05/15/13. The patient was admitted on 05/13/13 at 3:10 PM with diagnoses of persistent venous stasis ulcers. The medical record contained nursing interventions that included reminding and assisting Patient 7 with turning and repositioning every two hours and I and O monitoring. The medical record did not have documentation Patient 7 was assisted with turning and positioning at least every two hours on 05/13/13, 05/14/13, and 05/15/13. The I and O records did not have documentation of three meals per day and output. Further review of the medical record revealed there was no documentation the patient was provided oral hygiene.

This finding was verified by Staff A on 05/15/13 at 11:45 AM.

8. The medical record for Patient 8 was reviewed on 05/15/13. The patient was admitted on 05/13/13 at 1:48 PM. The patient had continuous tube feedings, was on a ventilator, had an indwelling urinary catheter and was unconscious. The patient had orders dated 05/13/13 for continuous tube feeding, I and O monitoring, ventilator, and turning and repositioning every two hours. The medical record did not have documentation Patient 8 was turned and repositioned at least every two hours on 05/13/13, 05/14/13, and 05/15/13. The patient's Braden scores were 12 to 13. The I and O record did not included documentation of tube feeding on 05/13/13 and the output lacked documentation of bowel movements. There was no documentation in the medical record that oral care was provided on 05/13/13 by nursing or respiratory therapy and no documentation of oral hygiene on 05/14/13 twice by nursing.

This finding was verified by Staff D on 05/15/13 at 3:00 PM.

9. The medical record for Patient 11 was reviewed on 05/13/13. Patient 11 was admitted on 04/12/13 at 2:14 PM with diagnosis of acute respiratory failure. Patient 11 was on a ventilator, continuous tube feeding, had an indwelling urinary catheter and was bed bound per the nursing assessment. The I and O record did not include documentation of tube feeding on 04/12/13, 04/14/13, 04/15/13, 04/18/13 and 04/29/13, and the output lacked documentation of a bowel movement until 05/04/13. The medical record contained an order dated 04/13/13 for turning and repositioning every two hours. For the period of time between 04/13/13 - 05/07/13, there was no documentation Patient 11 was consistently turned every two hours and remained in the same position (left, right or supine) for four, five, six or eight hours at a time. Patient 11 developed a hospital acquired sacral wound on 04/26/13. The medical record also lacked documentation of oral care by nursing staff twice a day.

10. The medical record for Patient 12 was reviewed beginning on 05/13/13. Patient 12 was admitted on 03/22/13 with a diagnosis of acute respiratory failure. Patient 12 was non-verbal, bed bound, on a ventilator with continuous tube feeding, an indwelling urinary catheter and a rectal tube. The medical record lacked documentation of oral care twice a day. The Respiratory Care Routine Responsibilities policy was reviewed on 05/16/13. The policy stated that respiratory therapists are responsible for providing oral care per shift and as needed. On 05/14/13 at 11:39 AM, Staff B confirmed oral care was not provided twice a day as per policy. At that time Staff B stated oral care was supposed to be provided four times a day for patients on a ventilator, twice by nursing staff and twice by respiratory therapy. Respiratory therapy did not begin providing oral care until 04/20/13 (29 days post admission) after obtaining an order.

The medical record for Patient 12 also contained an order dated 03/25/13 for turning and repositioning every two hours. Review of the documentation related to turning and repositioning revealed the patient was not properly turned every two hours from right side then to supine (back) then to left side and back to supine position again. The pattern was to be repeated. From 03/22/13 to 05/13/13, Patient 12 was noted to be lying in the same position (either left, right or supine) for four, five, six or more hours at a time.

Staff A was made aware of and confirmed the above findings related to turning and repositioning on 05/14/13 at 4:01 PM.

Staff A was interviewed on 05/14/13 at 2:10 PM. Staff A stated that the facility's expectation for patient's receiving tube feedings, total parenteral nutrition and intravenous fluids would be for intake and output to be documented every shift and the facility works twelve hour shifts. In addition Staff A stated that patient's with a moderate to high risk Braden score would be turned and repositioned at least every two hours. Oral care should be done twice a day by the nursing staff and if respiratory therapy is involved they should also be doing oral care twice a day.

These findings substantiate the allegations contained in substantial allegation OH00069715.

Based on medical record review, policy review, and staff interview the facility failed to ensure care plans were developed and updated with any changes for six of the ten medical records reviewed for Patients 1, 2, 4, 8, 11, and 12. The facility had a census of 67.

Findings include:

1. The medical record for Patient 1 was reviewed on 05/13/13. The patient was admitted on 05/07/13 at 6:27 PM with a diagnosis of stroke and malnutrition. The patient had continuous tube feeding ordered, was bed bound, had left sided weakness, a flaccid right side, and had an indwelling urinary catheter. The patient had a restraint order dated 05/08/13 at 12:00 AM. and documentation that a left mitt restraint was applied on 05/07/13 at 7:28 PM due to the patient pulling at tubes. The facility's policy for "Use of Physical Restraint for Medical Non-Violent, Non-Self Destructive Behavior" was reviewed on 05/13/13. The policy stated to modify the care plan to include the safety issue that resulted in the need for restraints, measurable outcome-oriented goals, interventions to minimize restraint use, alternatives tried to end restraint use, on-going evaluation of the restraints, and patient/family education regarding restraints. As of 2:47 PM on 05/13/13, the care plan lacked documentation of restraint use and interventions.

This finding was verified by Staff A.

2. The medical record for Patient 2 was reviewed on 05/14/13. the patient was admitted on 04/23/13 at 6:25 PM with diagnoses of acute/chronic respiratory failure, chronic renal failure, and sepsis. The patient had a tracheostomy, was on a ventilator, had a pressure ulcer on admission, and had a continuous tube feeding. The care plan did not contain interventions for decreased mobility and skin breakdown prevention until 05/13/13, three days after admission.

This finding was verified at 11:30 AM on 05/14/13 by Staff A.

3. The medical record for Patient 4 was reviewed on 05/14/13. the patient was admitted on 05/10/13 at 6:58 PM with a diagnoses of respiratory failure, delirium, and encephalopathy. the patient was receiving continuous tube feeding. the plan of care lacked interventions for nutrition and decreased mobility and skin prevention until 05/13/13, three days after admission.

This finding was verified by Staff A on 05/14/13 at 4:00 PM.

4. The medical record for Patient 8 was reviewed on 05/15/13. The patient was admitted on 05/13/13 at 1:48 PM. The patient had continuous tube feedings, was on a ventilator, had an indwelling urinary catheter, and was unconscious. The care plan lacked interventions for nutrition until 05/15/13, two days after admission.

This finding was verified by Staff D on 05/15/13 at 3:00 PM.

5. The medical record for Patient 11 was reviewed on 05/13/13. Patient 11 was admitted to the hospital on 04/12/13 with diagnosis of acute respiratory failure. The nursing admission assessment indicated Patient 11 was able to follow two step commands and "mouths words due to trach." Patient 11's breathing was "regular and unlabored" and lacked any additional assessment of the tracheostomy. The nutritional assessment indicated Patient 11 was on continuous tube feeding but the type of feeding tube (PEG, PEJ, NG, etc) was not specified. Patient 11's urine was "clear, yellow" with "indwelling catheter." Patient 11's skin was described as "not intact" and his/her activity level was "bed bound." There was no documented Braden Scale that indicated Patient 11's risk for additional skin breakdown.

On 05/13/13 at 2:00 PM, Staff B confirmed nursing failed to develop a care plan for Patient 11 at the time of admission.



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6. The medical record for Patient 12 was reviewed on 05/13/13. Patient 12 was admitted to the hospital on 03/22/13 with diagnosis of acute respiratory failure. The nursing admission assessment indicated Patient 12 was non-verbal, responded to stimuli (type of stimuli not specified) and that he/she tracked "at times." Patient 12's breathing was "regular and unlabored" and there was no documentation of an artificial airway. The nutritional assessment indicated Patient 12 was on a continuous tube feeding but the type of feeding tube (PEG, PEJ, NG, etc) was not specified. Patient 12's urine was described as "clear, yellow colored, normal" without documentation of a catheter in place. A skin assessment indicated the patient was "at high risk" per Braden Scale score of 8. Patient 12's activity level was defined as "bed bound." Review of the transfer papers for Patient 12 indicated he/she also had a PEG tube, tracheostomy, an indwelling urinary catheter and a rectal tube in place at the time of admission.

The corresponding nursing care plan developed the day of admission (03/22/13) had one diagnosis: "Potential impaired skin integrity related to Braden scale prevention." Interventions included using two people and a lift sheet during repositioning and avoiding placing patient on trochanter. The nursing care plan did not address Patient 12's mental, respiratory, nutritional, gastrointestinal/urinal, or activity/mobility status. Staff D was made aware of and confirmed the above findings related to Patient 12's admission assessment and care plan on 05/14/13 at 1:32 PM. At that time, Staff D stated the care plan was interdisciplinary.

Per review of Patient 12's history and physical completed on 03/23/13, the physician assessment of Patient 12 noted the following diagnoses: infectious meningitis, acute respiratory failure, severe encephalopathy, dysphasia, malnutrition and deep vein thrombosis prophylaxis. Patient 12 was noted to have a tracheostomy and PEG tube in place. The physician's plan for Patient 12 included monitoring the PEG site for cleanliness and hygiene, control of bladder and bowel hygiene and seizure precautions. The medical record lacked any documentation to indicate nursing implemented seizure precautions for Patient 12.