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Based on policy and procedure review, clinical record review and interview, it was determined the Facility failed to ensure a current and comprehensive nursing care plan was developed and implemented based on the patient's needs for 7 (#3, #4, #8, #9, #10, #13 and #15) of 15 (#1- #15) patients. Failure to develop and maintain a current and comprehensive plan of care was likely to affect the nursing care rendered to ensure the patients received optimum care to progress and be discharged. The failed practice affected Patient #3, #4, #8, #9, #10, #13 and #15. Findings follow:

1. Patient #3 was admitted 04/13/2015. On admission problems (Urinary Elimination, Gastrointestinal Function, Impaired Skin Integrity, Prevention of Infection, Impaired Comfort, Impaired Safety, Medication Management, Coping Mechanism, Participation in Plan of Care, Alterations in Mobility and Alteration in Nutrition) were identified and marked on the Nursing Care Plan with interventions/actions to be taken. As of 05/11/15 there were no changes in the interventions/action, no additional problems and no goals met.
2. Patient #4 was admitted 05/05/15. On admission 11 problems (Urinary Elimination, Decreased Cardiac Tissue Perfusion, Skin Integrity, Prevention of Infection, Impaired Comfort, Impaired Safety, Medication Management, Coping Mechanism, Discharge Planning, Communication and Nutrition. The Nursing Care Plan did not address Patient 16 ' s constipation.
3. Patient #5 was admitted 12-05-14. On admission 9 problems (Alterations in Self Care, Communication, Nutrition, Coping Mechanism, Discharge Planning, Impaired Comfort, Impaired Skin Integrity, Prevention of Infection, Deficient or Excess Fluids) were identified and marked on the Nursing Care Plan with interventions/actions to be taken. As of 12/18/14 there were no changes in the interventions/actions, no additional problems and no goals met. The Nursing Care Plan did not address Patient #5 ' s Urinary problems, Confusion, Anxiety, Apnea and Weakness.
4. Patient #6 was admitted 04/24/15. On admission 3 problems (Alteration in Elimination, Deficient or Excess Fluids and Impaired Skin Integrity) were identified and marked on the Nursing Care Plan with interventions/actions to be taken. As of 05/11/15 there were no changes in the interventions/actions, no additional problems and no goals met.
5. Patient #8 was admitted 04/17/15. On admission 5 problems (Urinary Elimination, Coping Mechanism, Discharge Planning, Nutrition and Communication) were identified and marked on the Nursing Care Plan with interventions/actions to be taken. As of 05/11/15 there were no changes in the interventions/actions, no additional problems and no goals met. The Nursing Care Plan did not address Patient #8 ' s Insomnia, Confusion, Pain, Weakness and Lethargy
6. Patient #9 was admitted 04/16/15. On admission 7 problems (Alteration in Gastrointestinal Function, Urinary Elimination, Decreased Cardiac Tissue Perfusion, Prevention of Infection, Alteration in Self Care, Alteration in Communication and Alteration in Mobility) were identified and marked on the Nursing Care Plan with interventions/actions to be taken. As of 04/28/14 there were no changes in the interventions/actions, no additional problems and no goals met. The Nursing Care Plan did not address Patient #9 ' s anxiety.
7. Patient #10 was admitted on 04/24/15. On admission eight problems (Self Care, Communication, Pulmonary Status, Mobility, Impaired Skin Integrity, Deficient or excess Fluids, Medications and Coping Mechanism) were identified and marked on the Nursing Care Plan with interventions/actions to be taken. As of 05/11/15 there were no changes in the interventions/actions, no additional problems and no goals met. The care plan did not address Patient #10 ' s mental confusion.
8. Patient #13 was admitted 04/13/15. On admission five problems (Pain, Medication Management, Coping Mechanism, Mobility and Nutrition) were identified and marked on the Nursing Care Plan with interventions/actions to be taken. As of 05/11/15 there were no changes in the interventions/actions, no additional problems and no goals met. The care plan did not address Patient #13 ' s pressure ulcer nor the problems with the urine elimination.
9. Patient #15 was admitted 03/27/15. On admission 5 problems (Risk for Cardiac perfusion, Deficient or Excess Fluids, Risk for Impaired Skin Integrity, Impaired Comfort and Alteration in Pulmonary Status) were identified and marked on the Nursing Care Plan with interventions/actions to be taken. As of 05/11/15 there were no changes in the interventions/actions, no additional problems and no goals met.

10. The lack of change in the interventions/action and no additions or met goals on the Nursing Care Plan was confirmed at the time of the record review by the Director of Nursing and the Director of Quality.

11. Review of Policy #CL-2.3 Multidisciplinary Care Plan received on May 08 from the Director of Quality revealed under Evaluation the following:
Evaluation
Determining the degree of effectiveness of the actions taken to affect problem resolution. Evaluation assists the clinical team and patient in determining what problems have been resolved and how to modify the existing Multidisciplinary Plan of Care. Evaluation also assists the team to identify new or recurring problems/needs. It is systematic and ongoing ...