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Based on interview and review of records, nursing staff failed to keep the nursing plan of care up to date in 1 (Patient #1) out of 7 patients (Patient #'s 1, 2, 4, 5, 6, 7, and 8) reviewed.

On 2-8-2017 at approximately 2:05 p.m., a review of Patient #1's chart was completed with Staff #4. Patient #1 was ready to be discharged home with family. All documents had been prepared and discharge instructions had been given to the patient's family. Upon review of the electronic chart and plan of care, patient was to be turned every 2 hours to prevent pressure ulcers (wounds that occur in patients who are not able to reposition themselves frequently). No documentation of the turning or the patient response to the turning was found.

Interview was conducted with Staff #4. Staff #4 was asked what position Patient #1 had been in 2 hours prior to our interview. Staff #4 paused for a moment, then said, "Her left." When asked how she knew and if she had that written down somewhere, Staff #4 stated, "I just know. I'm the one who positioned her." Staff #4 stated that she had been very busy with her patient assignments and had not had time to open up her charts yet, other than to chart medication administration. When asked if she had written notes down to chart from at a later time, Staff #4 did not have any notes. Staff #4 confirmed that she was going to chart everything from memory.

Interview with Staff #3 was completed. Staff #3 stated that the census had been very high and everyone was busier than usual. Staff #3 stated that Staff #4 had 5 patients assigned to her. Staff #3 stated it was not the usual practice to chart from memory after patient discharge.

Patient #1's complete chart was transferred electronically to compact disc on 2-8-2017 at 2:21 p.m. Review of Patient #1's chart showed that no shift nursing assessment had been documented by Staff #4 on 2-8-2017. The record showed the Nursing Care Plan had last been reviewed on 2-7-2017 at 7:28 a.m. The patient care activity section showed only one entry for Staff #4 at 12:04 p.m. that documented "Discharge or Transfer Checklist - Mandatory!!" No other entry was found. Vital signs were documented on 2-8-2017 by the night shift nurse. Staff #4 documented the first set of vital signs at 11:22 a.m.

Review of College Station Medical Center Policy titled "Plan of Care (Nursing)"; Policy/Procedure # Section 2.17 stated the following:

Reference: II Procedures; D. Assessment/Re-Assessment = A; 9. "The licensed nurse will document the complete systems review at the beginning of the shift but may indicate at midshift "no change" in the appropriate space if no change in patient status has occurred. However, the RN may not use the "no change" for the reassessment required every 24 hours."

F. Interventions = I 4. "Common interventions will be documented in the electronic medical record."

Based on review of records and interview, the discharge planning assessment was not initiated in a timely manner for 1 (Patient #4) out of 7 patients (Patient #'s 1, 2, 4, 5, 6, 7, and 8) reviewed.

On 2-9-2017, a tour of the Intensive Care Unit (ICU) was conducted. Patient #4 was in ICU room #2. Patient #4's record showed that the patient was admitted on 2-4-17 and the physician had ordered a discharge planning consult for Case Management at the time of admission. No Case Management notes were found.

Interview was conducted with Staff #8 in the Case Management office. Staff #8 confirmed she was the person responsible for completing the Discharge Planning Evaluation for Patient #4. Staff #4 confirmed that she had not completed the discharge planning interview with the family and had not completed the discharge planning evaluation.

Review of College Station Medical Center Policy titled Discharge Planning, Policy / Procedure # Section 5.3 was conducted. The policy stated as follows:

II. Procedure:

"3) Patients referred for focused discharge planning, through Nursing Admission Assessment triggers, will receive an initial discharge planning interview by the Case Manager within 72 hours of trigger. All physician referrals will be assessed within 24 hours, or by the close of the next business day from the time of order origination. On-call Case Manager may be contacted on the week-end for assistance as needed to provide direction/oversight. Reassessment occurs during the Case Manager's continued stay reviews approximately every 72 hours with revision to the Plan of Care as appropriate. The discharge planning interview will:
a) Assess anticipated LOS (length of stay) and/or any recent stay at College Station Medical Center.
b) Review identified/anticipated discharge needs based on: age, marital status, place of residence, next of kin, diagnosis and/or social or psycho/emotional history. Living situation and caregiver situation, as well as financial situation, will be reviewed as needed.
c) Assess patient/family/significant other abilities to understand and assist in post discharge needs as well as the patient's responsibility for the care of others.
d) If a patient exercises the right to refuse discharge planning or to comply with the discharge plan, documentation of this refusal will be recorded in the medical record."

Based on observation, review of records and interview, the discharge planning assessment was not reassessed to identify new or changing needs for 2 (Patient #s 1 and 2) out of 7 patients (Patient #'s 1, 2, 4, 5, 6, 7, and 8) reviewed.

A tour of the telemetry (remote monitoring of patient's heart) unit was completed on 2-8-2017. Patient #1 was pending discharge. Review of the patient chart revealed that the patient was an undocumented resident and had no health insurance. She had broken her hip previously with a repair. The hardware for the hip repair had become infected and she had been admitted for hardware replacement. The patient also had a wound to the right lower extremity.

Review of the patient discharge plan and discharge instructions did not address the wound to the right lower extremity. Staff #3 was in the patient room assessing the bandage on the right lower extremity when the patient's granddaughter asked how they were supposed to care for the dressing. The granddaughter explained that Staff #4 had given them instructions for the hip incision, but not the bandage on the lower extremity. Staff #3 stated she would speak with Staff #4.

Staff #4 was interviewed. Staff #4 was asked what instructions she had given the patient concerning dressing changes. Staff #4 stated the patient was to leave the dressing in place until her appointment time in two weeks. When asked what restrictions to bathing the patient would have due to the dressing, Staff #4 stated, "None. It's waterproof." When it was pointed out that the patient had a dressing to the lower extremity that was not waterproof, Staff #4 stated, "The doctor didn't write any orders for that." Staff #4 confirmed that she had not contacted the physician for orders.

Interview with staff #6 revealed that there were several agencies that provided assistance to undocumented residents for medical needs. Staff #6 confirmed that there was no documentation that a referral to any of these agencies had been made or that the patient had been given this information to assist with home health, dressing change supplies, or physical therapy needs.

Review of Patient #2's chart was made. The discharge plan indicated the patient would go home with home health. After the patient had been given discharge instructions, the Case Manager found out the physician had refused to sign an order for home health. No evidence of reassessment of the discharge needs was found. The patient was discharged home and told to call the doctor if they had any problems. This was done on a Friday afternoon.

Interview was conducted with Staff #6. Staff #6 confirmed that there was no reassessment of needs documented in the chart since home health was no longer available for the patient and family.