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Based on record review and staff interview, it was determined the CAH failed to ensure nursing care plans were developed, individualized, or kept current based on nursing assessments in 10 of 10 records (#1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) reviewed. This had the potential to negatively impact quality, thoroughness, and coordination of patient care. Findings include:

An undated CAH policy, "Care Planning," stated care planning was to be individualized according to the patient's needs, strengths, limitations, goals, and diagnoses. Care planning was expected to be based on data collected from assessments and would be regularly reviewed and revised. The policy did not specifically address how nursing staff were expected to individualize pre-printed nursing care plans or show evidence of revisions.

A staff RN was interviewed on 5/04/10 at 1:40 PM. She explained that the admitting RN completed the initial patient assessment and subsequently developed a care plan based on the nursing assessments. Some care plans were standardized and some hand written. When asked how the pre-printed care plans were individualized for patients, she explained that relevant information was circled, or initialed and information that did not apply would be crossed out. She stated if patient health conditions affected patient care, then the information should be addressed on a care plan. If a physician ordered a discipline, such as PT, OT, ST, or swallowing evaluation, it should be included on the patient's care plan. She stated if a patient was assessed to be at high risk for falls, then the fall risk protocol should be initiated and placed in the patient's medical record. Similarly, if a patient was determined to be at risk for skin breakdown, then the skin protocol should be initiated and placed in the medical record.

During an interview on 5/03/10 at 3:15 PM, the Director of Medical-Surgical Unit acknowledged the green pre-printed care plans were not individualized. She stated it was a concern to her and she planned to do some work around improving the care planning process.

In the following examples, the CAH failed to either individualize pre-printed care plans or to utilize assessment data to develop or revise care plans based on assessment findings.

1. Patient #8 was an 86 year old female admitted on 3/14/10. A History and Physical Report, dated 3/15/10, indicated Patient #8 arrived in the ED with vomiting and diarrhea and had a urinary tract infection. She was assessed to be dehydrated. She also had a history of Alzheimer's dementia with aggressive behaviors. The Initial Nursing Assessment, dated 3/14/10, documented the patient was verbally abusive/yells/swears and was physically abusive/combative. She was assessed to be at high risk of falls. She was also assessed to have a reddened area above her coccyx.

There were no care plans present in the medical record that addressed aggressive behaviors, fall risk, dehydration, diarrhea, or risk for skin breakdown. There was a care plan that addressed "urinary tract infection." During an interview on 5/04/10 at 12:00 PM, the Director of the Medical-Surgical Unit reviewed the record and confirmed the findings. Care planning was incomplete.

2. Patient #4 was a 92 year old male admitted to the hospital on 3/13/10 for weakness. An Admission Assessment, dated 3/13/10, indicated Patient #4 was assessed to be at high risk for falls. He also had dementia. There were no nursing care plans present in his medical record.

During an interview on 5/02/10 at 3:15 PM, the Director of the Medical-Surgical Unit reviewed Patient #4's medical record and confirmed the findings. At 3:55 PM on 5/03/10, she provided a copy of a pre-printed "fall risk care plan" and stated if a patient was assessed to be at fall risk she would expect to see the care plan in the medical record.

3. Patient #9 was a 94 year old female admitted to the hospital on 4/05/10 for care related to a pulmonary embolism. She also had a history of diabetes, urge incontinence, and fatigue. She was assessed at admission by nursing to be at high risk for falls. There were no nursing care plans present in Patient #9's medical record. During an interview on 5/04/10 at 3:15 PM, the Chief Nursing Officer reviewed the medical record and confirmed the findings. She stated the care plans may have been transferred to a swing bed chart; however, she was not able to verify this information.

4. Patient #1 was a 73 year old female who had knee surgery on 4/26/10. Nursing documentation, dated 4/28/10, documented nursing interventions and/or medical treatments for Patient #1 to include CPM machine, hemovac drain, foley catheter, TED hose, and PCA pump. These interventions were not included in Patient #1's care plan.

A pre-printed care plan, "Knee Replacement," was present in her medical record. It did not include Patient #1's name on it. The care plan included nine pre-printed nursing diagnoses with corresponding outcomes and interventions. None of the nursing diagnoses, outcomes, or interventions were checked or circled to indicate they had been individualized or specifically selected for Patient #1. Three of the nursing diagnoses had hand written dates next to the diagnoses stating they had been started, evaluated, or met. Six of the nursing diagnoses did not have any individualized dates or notes written next to them. It was unclear as to which pre-printed interventions were relevant and being implemented.

During an interview on 5/03/10 at 3:15 PM, the Director of Medical-Surgical Unit acknowledged the pre-printed care plans were not individualized and stated she was working towards improvement in this area. She stated she was unsure if nursing staff were re-evaluating the care plan on a daily basis.

5. Patient #6 was an 86 year old male admitted on 4/13/10 with chest pain and a pulmonary embolus. He was treated during the hospitalization with anticoagulation therapy to "thin the blood." An undated discharge instruction sheet, titled "Warfarin and Anticoagulation Therapy," cautioned against the dangers of the therapy and the importance of taking the therapy seriously to avoid grave consequences, including death and disability.

A pre-printed care plan, dated 4/15/10, addressed the need to monitor and address Patient #6's pain. However, there was no care plan in the medical record to address monitoring for side effects of the medication during the admission or educating the patient/caregiver regarding the risks and side effects of the medication. Although the hospital had a pre-printed care plan to address nursing care interventions related to pulmonary embolism, the care plan was not included in Patient #6's medical record. During an interview on 5/04/10 at 11:45 AM, the Director of the Medical-Surgical Unit reviewed the record and confirmed the findings.

6. Patient #3 was an 81 year old female admitted to the hospital on 3/05/10 with a primary diagnosis of pneumonia. Secondary diagnoses included, but were not limited to, dementia, dehydration, diabetes, dysphagia, malaise and fatigue. Physician orders, dated 3/08/10, called for PT evaluation and treatment for ataxia and weakness and a speech evaluation related to aspiration risk. Physician orders, dated 3/09/10, called for Patient #3 to sleep on a wedge pillow and receive intermittent supervision during meals to avoid aspiration. None of these orders were incorporated into care planning. During an interview on 5/04/10 at 11:55 AM, the Director of the Medical-Surgical Unit reviewed the record and confirmed the findings.

The medical record included a pre-printed care plan, titled "Pneumonia" which included five related nursing diagnoses. None of the nursing diagnoses, outcomes, or interventions were checked or circled to indicate they had been individualized or specifically selected for Patient #3. One of the nursing diagnoses had hand written dates next to the diagnosis stating it had been initiated and evaluated. Four of the nursing diagnoses did not have any individualized dates or notes written next to them.



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7. Patient #10 was an 87 year old male admitted to the hospital on 3/23/10 via the emergency room. The History and Physical Report, completed by the physician on 3/23/10, indicated he presented with a fever of unknown origin and he was to be evaluated for sepsis. The Identification and Background Information form was completed by the nurse on 3/23/10, and indicated Patient #10 was at a high risk for falls.

A pre-printed care plan titled "fever of unknown origin" was located in Patient #10's medical record. It contained three problems related to this diagnosis, with corresponding outcomes, time frames, and interventions. At the bottom of the page, a nurse indicated the care plan had been initiated on 3/23/10 at 2:00 PM. A second nurse documented the care plan had been evaluated on 3/24/10. A third nurse documented the patient had been discharged on 3/25/10 at 9:15 AM. No additional documentation was present to indicate which outcomes and interventions were pertinent for Patient #10.

A physician's progress note, dated 3/24/10 at 7:50 AM, was hand written in the medical record. The physician noted that the urine culture was positive, therefore the fever of unknown origin was likely related to a urinary tract infection/urosepsis.

The "24 Hour Record," dated 3/24/10, indicated that the day shift and the night shift RNs had evaluated the care plan. However, the care plan was not updated to reflect the new, more specific, diagnosis of urinary tract infection. An updated care plan would have included problems, outcomes, and interventions specific to a urinary tract infection.

The Chief Nursing Officer was interviewed on 5/04/10 at 3:24 PM. She reviewed Patient #10's medical record. She agreed that she would have expected the care plan to be updated and revised in accordance with the change in diagnosis from fever of unknown origin to urinary tract infection/urosepsis. She stated a care plan related to Patient #10's high risk for falls should have been included in the medical record.

8. Patient #2 was a 95 year old female admitted to the hospital on 4/25/10, after being treated in the emergency room where she was taken after being found on the floor by family members. The History and Physical Report, completed by the physician on 4/25/10, indicated she was treated for pneumonia, peripheral edema, and bilateral knee osteoarthritis.

Admitting physician orders from 4/25/10 at 10:20 PM, included placing Patient #2 on aspiration and fall precautions and evaluation by physical and occupational therapy. However, these orders and subsequent treatments were not found on a care plan for Patient #2. Nursing narrative notes dated 4/26/10 at 1:00 PM, documented the RN "Placed sacral dressing to sacrum due to very red, non-blanching skin that has two areas that appear to be on the verge of broken skin." However, the medical record did not contain a care plan around pressure ulcer treatment or prevention.

The care plan for Patient #2 was a pre-printed care plan titled "Pneumonia." The document included five pre-printed nursing diagnoses with corresponding outcomes, time frames, and interventions. The document was marked at the bottom of the first page with the date 4/27/10, an RN's signature, and the word "initialed [sic]." The care plan did not contain Patient #2's name, and there was no indication that the care plan had been individualized for Patient #2 with appropriate outcomes and/or interventions selected. In addition, the medical record did not contain a care plan to address Patient #2's issues such as peripheral edema, aspiration and fall risks, skin integrity, or the osteoarthritis which was addressed by therapy services and trial medications.

A staff LPN was interviewed on 5/03/10 at 3:25 PM. She stated that a patient who was evaluated to be a fall risk will be identified by a symbol placed on the door of their room. She stated there was a fall risk care plan; however staff generally passed along information related to fall risk interventions during oral report given at shift change.

The Chief Nursing Officer and the Director of the Medical-Surgical Unit were interviewed together on 5/04/10 at 11:45 AM. They reviewed Patient #2's medical record and agreed that issues such as mobility related to arthritis, fall risk, and skin integrity should have been addressed in a care plan, and that the care plan related to pneumonia was not individualized.

On 5/04/10 at 12:35 PM, the Chief Nursing Officer presented pre-printed care plans available to staff related to alterations or potential alterations in skin integrity, altered oral and/or nutritional status, and alterations in respiratory functions. She stated she would expect the appropriate care plan to be in the medical record.

9. Patient #7 was an 82 year old male admitted to the hospital on 4/04/10 for treatment of pneumonia. The History and Physical Report, dictated by the physician on 4/04/10, indicated Patient #7 had additional diagnoses of diabetes, hypertension, mild renal insufficiency, elevated blood lipid levels, and COPD. The Identification and Background Information form, completed by a nurse on 4/04/10, indicated Patient #7 was at a high risk for falls.

The care plan found in Patient #7's medical record was a pre-printed care plan titled "Pneumonia." Hand written notes on the first page of the care plan indicated the plan was implemented on 4/04/10 at 11:00 PM. A second notation indicated the care plan had been evaluated on 4/06/10 at 3:15 AM. The care plan did not contain Patient #7's name and was not marked in any way to indicate which problems, outcomes, or interventions were applicable to him.

Patient #7's medical record did not contain a care plan related to fall risk or any of his secondary diagnoses. The Chief Nursing Officer and the Director of the Medical-Surgical Unit were interviewed together on 5/04/10 at 11:45 AM. They reviewed Patient #7's medical record and confirmed lack of adequate care planning. The Director of the Medical-Surgical Unit stated that Patient #7's COPD was troublesome for him during his hospitalization and required interventions.

10. Patient #5 was a 75 year old male admitted to the hospital on 4/05/10, subsequent to a left total knee arthroplasty. The Identification and Background Information form was completed by the surgical nurse prior to surgery on 4/05/10. It indicated Patient #5 had a history of diabetes, hypertension, arthritis, and an anxiety disorder. According to this document, Patient #5 was not considered a fall risk prior to surgery. However the fall risk assessment was not repeated once surgery had been completed.

Nursing documentation revealed Patient #5's blood glucose level ranged from 150 to 240. According to the American Diabetes Association, at www.diabetes.org, with a copyright of 2010, the normal range for blood glucose was 70-130 (fasting level) to less than 180 (after a meal). Documentation on 4/07/10, in the "24 Hour Record," indicated Patient #5 consumed several pieces of chocolate candy which he believed were sugar free. His blood glucose was subsequently 240. The medical record did not contain information related to the physician's expectations for Patient #5's blood sugar levels or what, if any, education was needed or had been discussed. No care plan related to diabetes had been initiated.

The medical record did contain a care plan titled "Knee replacement." The pre-printed care plan contained nine nursing diagnoses along with outcomes, time frames, and interventions. Hand written documentation, which included dates and the RN's signature at the bottom of the first page of the care plan, indicated the care plan was started on 4/05/10, and evaluated on 4/06/10 and 4/07/10. The care plan did not contain Patient #5's name, and other than the above documentation, the care plan had not been marked to indicate appropriate outcomes and interventions specifically intended for Patient #5.

The pre-printed care plan for knee replacements did not contain pain control as a problem or potential problem for Patient #5. Therefore, the medical record did not contain a care plan for pain management for Patient #5 after his surgery.

The Chief Nursing Officer and the Director of the Medical-Surgical Unit were interviewed together on 5/04/10 at 11:45 AM. They reviewed Patient #5's medical record and agreed that the care plan was not individualized to meet Patient #5's needs. The Director of the Medical-Surgical Unit agreed the fall risk should have been re-evaluated after surgery. She stated that Patient #5 required guidance and re-education related to post-surgical protocols and diabetes management and agreed that these issues should have been addressed in a patient-specific care plan.

A staff RN was interviewed on 5/04/10 at 1:40 PM regarding the development and use of care plans. She reviewed Patient #5's medical record and stated that if a patient has a secondary diagnosis, such as diabetes for Patient #5, it should be addressed on a care plan. She also stated she thought pain management was addressed on the surgical care plans, however, after review confirmed this was not true for Patient #5.

The hospital failed to ensure care plans were developed, individualized, or kept current based on nursing assessments and patient needs.

Based on record review and staff interview, it was determined the CAH failed to ensure admission consent documentation was complete in 6 of 10 patients' records (#1, #3, #5, #6, #8, and #9) reviewed. This resulted in a lack of clarity as to the course and timing of consent. Findings include:

1. Patient #1's signature was on the Admission Consent for Treatment. However, the consent form was undated and untimed. During an interview on 5/03/10 at 11:30 AM, the Chief Nursing Officer reviewed the medical record and confirmed the missing date and time.

2. Patient #3 was an 81 year old female admitted to the hospital on 3/05/10. Patient #3's Admission Consent for Treatment was signed by an agent or representative. However, the consent form was undated and untimed. During an interview on 5/04/10 at 11:55 AM, the Director of the Medical-Surgical Unit reviewed the consent form and confirmed the findings.

3. Patient #6 was an 86 year old male admitted on 4/16/10. There was no Admission Consent for Treatment present in the medical record. During an interview on 5/04/10 at 11:45 AM, the Director of the Medical-Surgical Unit reviewed the medical record and confirmed the consent form was missing.

4. Patient #8 was an 86 year old female admitted on 3/14/10. Patient #8's Admission Consent for Treatment was signed by an individual that identified himself as having power of attorney. The consent form was undated and untimed. During an interview on 5/04/10 at 12:00 PM, the Director of the Medical-Surgical Unit reviewed the consent form and confirmed the findings.

5. Patient #9 was a 94 year old female admitted on 4/05/10. The Admission Consent for Treatment was signed and dated by the patient. The time the document was signed was blank. During an interview on 5/04/10 at 3:15 PM, the Chief Nursing Officer reviewed the consent and confirmed the time the consent was obtained was missing.



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6. Patient #5 was a 75 year old male admitted to the hospital on 4/05/10. The Admission Consent for Treatment was signed by Patient #5, but was not dated or timed. In an interview on 5/03/10 at 1:25 PM, the Chief Nursing Officer reviewed the medical record and confirmed the missing date and time.

The hospital failed to ensure admission consent documentation was complete, with date and time, and placed in the medical record.