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Based on interview and record review the facility nursing staff failed to develop a current care plan for 2 out of 10 sampled patients. (Patient ID# 's 1 and 8)

Finding include:
Patient # 1
A History and Physical dated 5/2/14 stated " Chief Complaint: The patient was transferred over from a hospital, post evaluation for altered mentation, rheumatoid arthritis, and septicemia. History: This is a 48-year old female, who was accompanied by her daughter when she was initially admitted at the hospital on 4/25/14. The patient came in complaining of feeling bad all over. According to the Daughter, the patient has been having symptoms of lethargy, altered mentation, and generalized weakness with poor nutritional intake for about 2 weeks. The patient has a long-standing history of alcohol abuse and use. In the last few months, the patient has become quite debilitated and has been unable to walk or get around.

The Initial Nursing Assessment on 5/1/14 stated " Neurological assessment: Patient is oriented to person, needs orientation to place and time. Anxious, confused, cooperative follows one stop command. Speech clear. Musculoskeletal Assessment: bed bound. "

Physical Therapy notes dated 5/15/14 stated " Bilateral wrist restraints on due to high risk of falls due to increased confusion and hallucination. " The Therapy notes further stated " Decreased Functional mobility: Precautions: Fall, Altered Mental Status. "

A Fall Risk assessment was done 5/2/14. A Fall risk score of 10 or greater places the patient at risk of Falls. Patient ID# 1 scored 19 on her Fall Risk Assessment. " Potential for injury related to age, impaired physical mobility, impaired thought process. "

The patient ' s Care Plan dated 5/1/14 listed the following problems:
-Anxiety related to diagnosis
-Alteration in comfort
-Potential for injury related to age, impaired physical mobility, impaired thought process. Patient will experience no injury, as measured by fall assessment. "
-Decreased functional mobility, patient will increase transfer skills.

The Care Plan failed to list interventions for the Risk of falls or the need for restraints.

A nursing note dated 5/22/14 at 11:45 stated " Patient was heard crying from the room. Arrived and found patient lying on back facing up with side-rails still up. In house Physician was called in to assess the patient. Abnormal x-ray left knee result .... "

A Physician progress note by the House Physician dated 5/22/14 at 16:52 stated " Left knee films show a displaced closed fracture of distal femur. Arrangement made to transfer to ER for treatment. "

Patient # 8
Patient ' s record reviewed on 09/02/2014 revealed the he was admitted on 04/25/2014 due to fall with cervical fracture. An Incident Report dated 4/27/14 at 10:45 p.m. stated that the patient fell from his bed described as " Patient found by the RN lying on the floor, with no injuries noted. Awake, moves all extremities after command " .
Patient had a high risk assessment score more than 10 upon initial admission. Patient Care Plan on 04/25/2014 identified " Potential for injury related to impaired physical mobility. Desired outcome: The following outcome(s) have been mutually agreed upon by Clinician and patient, family, healthcare provider. Patient will not fall, as measured by no injury during the hospital stay. Target date to achieve objective: 04/28/2014 " . No specific interventions to achieve these goals were noted on the care plan.
Interview Staff # 50 on 09/02/2014 at 12:30 noon, the Surveyor notified her that there was no specific intervention related to fall for this patient (ID# 8), she acknowledged there were no interventions on the Care Plan.