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Based on document review and interview, the facility failed to keep a current nursing care plan for each patient that reflects the patient's goals and nursing care to be provided to meet the patient's needs (P1, P7, P8, P9, P10).

Findings include:

1. Facility policy titled, Treatment Plan, policy number SS.01, last revised 12/2023, indicated the needs, strengths, preferences, and goals of the patient are identified based on the screening and assessment, and are used in the plan for care, treatment or services; every patient's treatment plan shall identify patient goals and associated objectives and interventions necessary to meet the identified goals; goals and objectives will be reevaluated and, as necessary, revised based on changes in the patient's condition, problems, needs and responses to care treatment and services; care, treatment or services for each patient is based on the plan for care, treatment or services; the initial plan shall include high risk and critical medical problems and appropriate physician and nursing interventions as determined by the initial assessments.

2. Medical Record (MR) review indicated the following:

a. Review of P1's MR indicated facility admission on 1/21/24. MR Admission Assessment on 1/21/24 indicated patient was incontinent of bowel and bladder. MR treatment care plan lacked nursing diagnosis and nursing interventions for maintenance of skin integrity.

b. Review of P7's MR indicated facility admission on 12/21/23 and facility discharge on 1/9/24. MR Admission Assessment indicated, patient was continent of bowel and bladder. MR AM Observation Record and PM Observation Record sheets indicated P7 was provided incontinence care during facility admission, including but not limited to: 12/21/23 am and pm shift, 1/3/24, am and pm shift, and 1/7/24 am shift. MR treatment care plan lacked nursing diagnosis and nursing interventions for maintenance of skin integrity.

c. Review of P8's MR indicated facility admission on 12/25/23 and facility discharge on 1/15/24. MR Admission Assessment indicated patient was incontinent of bowel and bladder. MR treatment care plan lacked nursing diagnosis and nursing interventions for maintenance of skin integrity.

d. Review of P9's MR indicated facility admission on 1/3/24 and facility discharge on 1/25/24. MR Admission Assessment indicated patient was incontinent of bowel and bladder. MR treatment care plan lacked nursing diagnosis and nursing interventions for maintenance of skin integrity.

e. Review of P10's MR indicated facility admission on 1/8/24 and facility discharge on 1/29/24. MR AM Observation Record and PM Observation Record sheets indicated patient received incontinence care during facility admission, including but not limited to: 1/10/24 am and pm shift, 1/14/24 am and pm shift, 1/21/24 am and pm shift, and 1/25/24 am and pm shift. MR treatment care plan lacked nursing diagnosis and nursing interventions for maintenance of skin integrity.

3. In interview on 1/31/24, at approximately 4:20 pm, A2 (Registered Nurse, Nurse Consultant [RN, NC]), verified toileting and skin care are done per nursing recommendations and nursing judgement based on assessments of the patient and should be put in the patient care plan. A2 verified no skin care nursing diagnosis or interventions were on P1, P7, P8, P9 and P10's Treatment Care Plans.