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Based on record review, staff interview, and review of Hospital policy, the Hospital failed to ensure nursing reviewed, revised and kept current a nursing care plan for ten patients (#1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), in a total sample of 10 patients.

Findings include:

1.) Hospital policy and procedure titled Nursing Care Planning indicated that patients plan of care shall be reviewed and updated at least daily by a licensed nurse. The care plan will be reviewed weekly by the interdisciplinary team at the scheduled patient care plan conference.

2.) The Surveyor reviewed the following care plans, with the Director of Case Management, on the 5th floor nursing unit, from 1:14 P.M. to 1:48 P.M. on 3/20/14, via the Hospital computer system.

a. Patient #1 was admitted 11/27/13 with diagnoses including a draining fistula (wound). The care plan was last reviewed by a registered nurse at 2:36 A.M. on 2/28/14 and last reviewed by a registered nurse at 2:36 A.M. on 2/28/14.

b. Patient #2 was admitted 10/3/13 with diagnoses including a blood infection. The care plan was last reviewed by a registered nurse at 2:36 A.M. on 2/28/14 and was last updated, by a respiratory therapist at 5:06 P.M on 2/19/14.

c. Patient #3 was admitted 2/27/14 with diagnoses including chronic respiratory failure. The care plan was not reviewed by a licensed nurse and was last updated, by a respiratory therapist, at 11:53 A.M. on 3/20/14.

d. Patient #4 was admitted 9/1/13 with diagnoses including acute and chronic respiratory failure. The care plan was last reviewed by a registered nurse at 6:45 A.M. on 2/19/14 and last updated by a physical therapist at 8:31 A.M. on 3/4/14.

e. Patient #5 was admitted 2/20/14 with diagnoses including spinal abscess. The care plan was last reviewed at 3:14 A.M. on 2/27/14 and last updated at 1:17 A.M. on 2/21/14 by two different registered nurses.

f. Patient #6 was admitted 7/15/13 with diagnoses that included respiratory failure. The care plan was last reviewed by a registered nurse at 2:28 A.M. on 2/28/14 and last updated by a speech therapist at 6:55 A.M. on 1/8/14.

g. Patient #7 was admitted 3/11/14 with diagnoses including kidney failure. The care plan was last reviewed by a registered nurse at 2:27 A.M. on 3/13/14 and last reviewed by a respiratory therapist at 11:57 A.M. on 3/20/14.

h. Patient #8 was admitted 2/21/14 with diagnoses to include a wound infection. The care plan was last reviewed by a registered nurse at 7:34 A.M. on 2/28/14 and last updated by a physical therapist at 3:36 P.M. on 3/10/14.

i. Patient #9 was admitted 2/7/14 with diagnoses including respiratory failure. The care plan was last reviewed by a registered nurse at 3:28 A.M. on 3/1/14 and last updated by a respiratory therapist at 4:09 P.M. on 3/11/14.

j. Patient #10 was admitted 3/10/14 with diagnoses including respiratory failure. The care plan was not reviewed and updated by a licensed nurse since admission.

3.) During an interview on 3/20/14 from 1:14 P.M. to 1:48 P.M. the Director of Case Management said the ten in-patients records reviewed with the Surveyor, were not reviewed and updated by a licensed nurse according to the facility's policies and procedures.