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Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current an individualized, comprehensive nursing care plan for each patient for 1 (#3) of 5 (#1,#2, #3, #4, #5) total sampled patients reviewed for care plans.

Findings:
A review of the hospital policy titled, "Documentation of Nursing Care", as provided by S2AdmAsst, as the most current, revealed in part: The CPG (Clinical Practice Guidelines) serve as the foundation of the Plan of Care that is individualized with linkage to assessments, interventions, education and goals. Planning of care is individualized to meet the patient's unique needs through PCS (Patient Care Summary) and CPG's. Problem identification and prioritization. Establish a plan. Individualize care to patient. Add specific individualized interventions form Plan of Care. Measure education and outcomes by customizing outcomes based on patient problems. Each patient will have a care plan that addresses their specific needs.

Patient #3
A review of Patient #3's medical record revealed the patient was admitted on 04/23/17 with an admit diagnosis of left femur fracture and had a surgical procedure. The review revealed other patient medical conditions to include in part: Alzheimer's dementia at an advanced stage. A further review of Patient #3's medical record revealed the patient was dependent on all ADLs (activities of daily living) and was unable to answer questions or follow commands or instructions and was unable to make safe choices regarding personal care needs. The patient had a care plan for impaired mobility and fall risk, infection, and post operative care needs. There was no care plan noted for Alzheimer's /Dementia or Impaired Cognition.

In a medical record review on 11/15/17 at 11:00 a.m. with S2RN of Patient #3's care plan, she indicated that there was no documented evidence of a care plan on the patient for Alzheimer's/Dementia or Impaired Cognition.

In an interview on 11/15/17 at 1:30 p.m. with S3RN, staff RN, she indicated that staff mostly develop care plans on the patient's admitting problems, except for Diabetes. A care plan would also be developed for Alzheimer's/Impaired Cognition since impaired cognition would affect the patient's discharge planning.

In an interview on 11/16/17 at 11:30 a.m. with S1RN, nurse manager, she indicated that patient care plans are created on admission and are updated each shift. The RN would develop a care plan based upon the patient's initial assessment and suggested problems would also be pulled over from the software system into the care plan screen. The RN has the option of saying yes or no to any problem or intervention. The RNs mostly develop care plans on the patient's admitting problems with exceptions based upon nursing assessments. She indicated that Patient #3 should have been care planned for Alzheimer's since it affected her post operative and ADL care needs.