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Based on observation, interview and record review, nursing staff failed to date and time Intravenous (IV) sites for three (3) of six (6) patients per facility policy (Patient ID #2, #4, #7).

Finding include:

Observation on 6/21/2017 at 0900 and 0915 revealed the following:

Patient#2 left peripheral on IV site was not dated or timed.

Patient#4's left peripheral IV site was not dated or timed.

Patient#7's left peripheral left IV site was not dated or timed.

Interview on 6/21/2017 at 0915 with Registered Nurse (RN) #53, she said "the IV should be dated, timed and labeled with initials."

Record review of the facility policy titled "Intravenous Administration" dated 9/2015 stated: "Intravenous Dressings:
a. Dressing will be labeled with date, time, and initials".

Based on observation, interview and record, nursing staff failed to maintain a current nursing care plans for five (5) out seven (7) patients (Patients #3, 4,7,9,14).

Findings include:

Patient #3
Record review of the Patient #3's Medical Administration Record (MAR) dated 6/20/2017 revealed that he received Labetalol 50 mg (milligram) IV for elevated blood pressure (B/P) of 185/88 at 1818.

Record review of Patient #3's nursing care plan failed to reveal blood pressure identified as a problem.

Patient #4

Observation on 6/21/2017 between 0900 and 0915 revealed Patient #4 had a left peripheral IV site.

Record review of Patient #4's nursing care plan failed to reveal IV site identified as a potential problem.

Patient #7

Record review dated 6/20/2017 revealed Patient #7 was admitted for a diagnosis of acute vomiting and gastric band removal.

Record review of Patient #6's nursing care plan failed to reveal gastrointestinal issues identified as a problem.

Patient #9

Record review of medical record dated 2/28/2017 revealed Patient #9 was admitted for nausea and vomiting, urinary tract infection and hypertension.

Record review of Patient #9's nursing care plan failed to reveal medical issues of gastrointestinal issues and blood pressure identified as problems.

Patient #14

Record review of medical record dated 6/20/2017 revealed Patient #14 was admitted for abdomen pain and alcohol cirrhosis.

Record review of Patient #14's nursing care plan failed to reveal gastrointestinal issues identified as a problem.

Interviews on 6/21/2017 between 0915 and 0920 with three (3) staff Registered Nurses (ID #51, #52, #53): all three (3) stated the patient issues identified above should have been addressed in the patients' nursing care plans.

Record review of facility policy titles "Nursing Plan of Care", dated 10/2014, stated: "Procedure: 1. Patients receive care and treatment based on an assessment if their needs ....severity of the disease, condition, impairment or disability. The data obtained from the assessment is used to determine and prioritize the patient's plan of care".