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Based on observations, interview, policy review, and record review, the facility failed to ensure care plans for seven patients (#4, #5, #1, #9, #7, #8 and #15) of seven patients reviewed had individualized problems, interventions and goals specific to the patients medical and nursing needs. The facility census was 16 on the Lindell campus and 28 on the St. Anthony campus.

Findings included:

1. Record review of the facility policy titled "Care Coordination and Discharge Planning" release date 06/20/16 showed:
RATIONAL:
-To assure care provided to each patient is based on an assessment of the patient's relevant physical, psychological and social needs.
-To establish a comprehensive information base for decision making about each patient's care.
-To determine the appropriate care, treatment and services to meet the patient's needs during hospitalization.
PROCEDURE:
-A Patient Plan of Care developed and recorded within 24 hours of admission by the Registered Nurse (RN) based on identified problems and patient specific needs.
-The licensed staff nurse(s), RN and/or Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN) may update the patient's needs/problems and plan of care based on results of clinical findings gathered by the licensed nurse.
-Appropriate care plans will be entered based on diagnosis, assessment and symptomatology.
-Care plans will be updated as needed based on patient's condition.

2. Observation on 09/19/16 at 2:30 PM showed Patient #4 with a tracheostomy (trach,a surgical procedure to create an opening through the neck into the windpipe) and on ventilator (vent) support (mechanical ventilation helps a person breath or breaths for a person).

Record review of Patient #4's History and Physical (H&P) showed she had previously undergone mitral valve replacement (surgical procedure in which a patient's diseased mitral valve, which is between the left atrium and left ventricle of the heart, is replaced) and also a left aortic groove repair (repair of the ruptured left ventricle). Her hospital stay was complicated with episodes of atrial fibrillation (irregular heartbeat) and acute renal failure (the kidneys suddenly can not filter waste from the blood) and she was on hemodialysis (process that uses man made filter to remove waste from the blood).

Record review of the Patient #4's care plan showed no problem, intervention or goals for the vent weaning (removing the patient from the vent), atrial fibrillation, acute renal failure and hemodialysis. The care plan showed a problem of risk for infection when there was an actual infection (the patient was on antibiotics) and showed no individualized interventions or goals.

3. Observation on 09/19/16 at 2:50 PM showed Staff N, Wound Nurse Registered Nurse (RN), prepared to remove the abdominal dressing of Patient #5. The abdominal wound was large and red with a large fistula (an abnormal tube like connection between two organs). The patients lower extremities had large red wounds.

Record review of Patient #5's H&P dated 08/06/16 showed the patient had a large abdominal would with a fistula and chronic ulcers (wounds or open sores that will not heal)
of his lower extremities with pyoderma gangrenosum (uncommon, ulcerative skin condition of uncertain cause) and ulcers. He had chronic pain syndrome and was receiving Total Parenteral Nutrition (TPN), a method of feeding that bypasses the the stomach and intestines.

Record review of Patient #5's care plan showed no individualized problem, interventions or goals for impaired skin integrity related to his lower extremities wounds. There was no care plan for his chronic pain or the nutritional support.

4. Observation on 09/20/16 at 8:44 AM, showed Staff H, RN prepared to administer medications to Patient #1. The patient had a tracheostomy and was not able to speak. Staff N was standing at the foot of the bed and the patient motioned for her to come closer. The patient's husband informed Staff H that she had to get very close to her so that she could hear her. Staff N, RN, and the patient's husband were at the foot of the bed conversing when the patient raised her hand and with a facial grimace mouthed the words stop talking. Patient #1's husband stated that she was very hard of hearing and that she most likely was just hearing "noise" from the conversation at the foot of the bed.

Record review of Patient #1's medical record showed no individualized care plan was developed for the patient's hearing deficit.

During an interview on 09/20/16 at 10:30 AM, Staff H, RN stated that she was unaware that Patient #1 had a hearing deficit.

5. Observation on 09/20/16 at 10:00 PM, showed Patient #9 with soft restraints (physical restraints which kept the arms immobile) on both wrists. He had a long incision of the head, an indwelling urinary catheter, tracheostomy and a Percutaneous Endoscopic Gastrostomy tube, (PEG, a tube is passed through the abdominal wall to the stomach to provide a means of feeding). He had skin breakdown of the left gluteal fold (the portion of skin on the left of the buttock crease).

Record review of Patient #9's H&P dated 09/20/16 showed the patient was a victim of assault and had multiple fractures of the face and a retrobulbar hematoma (rare, uncommon, sight threatening emergency that results in an accumulation of blood) over the eyes. He had a trach and PEG tube and underwent a craniotomy (surgical opening of the skull) for evacuation of a subdural hematoma (tiny veins between the surface of the brain and the outer covering stretch and tear allowing blood to collect and compress the brain) and was anemic (lacks healthy red blood cells which carry oxygen). He was to continue on his antibiotic treatment for pneumonia. The patient was admitted to the facility under a code name due to the violent assault and was allowed no visitors except his mother who must give a password.

Record review of Patient #9's care plan showed no individualized problems, interventions or goals for the wrist restraints, actual impaired skin integrity related to his PEG tube insertion site and head incision or impaired nutrition, pneumonia, anemia or his no visitor status.

6. Observation on 09/20/16 at 10:45 AM, showed Staff AA, Respiratory Therapist, entered the room of Patient #7 to administer trach care (cleansing of the skin around the opening and changing of the ties) and suction (clears mucus from the tracheostomy tube) the patient.

Record review of Patient #7's H&P showed the patient sustained a traumatic brain injury when he jumped out of a moving car. He had sustained a right and left subdural hematoma and developed respiratory failure. The patient had a trach and PEG tube and he was started on antibiotics for pneumonia. A Glascow Coma scale (the most common scoring system used to describe the level of consciousness in a person following a traumatic brain injury) showed a score of three (severe). The patient was on seizure precautions (ways to minimize injury during a seizure, which is when the brains electrical activity is periodically disturbed).

Record review of Patient #7's care plan showed no individualized problem, interventions or goals for actual impairment of skin integrity related to the PEG tube placement, impaired spontaneous ventilation related to the trach and vent, impaired mobility related to the patient being unable to reposition himself due to his level of consciousness, or actual infection related to pneumonia.

7. Observation on 09/21/16 at 1:52 PM, showed a handwritten note on a piece of paper taped to Patient #15's doorway that stated "hard of hearing."

Record review of Patient #15's H&P, dated 09/11/16 showed he was admitted to the facility on 09/09/16 for continued antibiotic therapy and wound care. It also showed a history of blindness in the right eye and hard of hearing with the use of hearing aids.

Record review of Patient #15's medical record showed no individualized care plan was developed for the patient's hearing or visual deficits.

During an interview on 09/21/16 at 2:35 PM, Staff O, Chief Nursing Officer stated that her expectation was that hearing and visual deficits were to be included in the care plan.

8. Record review of Patient #8's H&P dated 09/08/16 showed the patient had hospital acquired pneumonia, severe malnutrition (a diet that does not provide adequate calories or protein), PEG tube placement and Stage IV squamous cell carcinoma (final stage of skin cancer) of head and neck with metastasis (spreading) to the collarbone and head and neck pain.

Record review of Patient #8's care plan showed no individualized problems, interventions or goals for his actual infection of pneumonia, malnutrition with tube feedings, actual impaired skin integrity related to the PEG tube insertion site and his head and neck pain.

During an interview on 09/21/16 at 10:15 AM, Staff GG, Director of Quality Management, stated that the canned text is brought into the care plans but there are no individualized problems, interventions and goals for the patients.








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