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Based on record review and interview, for three of ten sampled patients (#3, #4, and #8), the Nursing Service failed to develop or keep a current nursing care plan that addressed medical nursing needs for patients.

Findings include:

The Hospital policy titled, Nursing Care Planning, effective June 12, 2020, indicated that within 24 hours of admission, all patients shall have a plan of care generated by the registered nurse. The nurse is responsible for reviewing, continuing and changing the plan of care as required every shift and as needed. The plan of care will be continually evaluated based on the patient's clinical condition, care goals, the plan for treatment, and revised as needed to meet the needs of the patient's changing condition.

Findings include:

1. The Nursing Service failed to develop Patient #3's Nursing Care Plan, for respiratory failure and aspiration pneumonia and to update the Nursing Care Plan for an accidental decannulation (the tracheostomy tube was dislodged from the airway).

The Physician's Admission History and Physical Examination (Hx and PE), dated 10/10/20, indicated Patient #3's assessment and plan included a primary problem of acute and chronic respiratory failure, with ventilatory weaning per the pulmonologist recommendations.

Review of the Nursing Care Plans indicated, Patient #3 had a problem with alteration in pulmonary status, there were no documentation of respiratory goals or interventions.

Review of the Progress Note, dated 10/10/20, indicated that the Rapid Response Team was notified when Patient #3 was found decannulated, awake, alert and confused, with good color, warm skin and in no respiratory distress, with an oxygen saturation level of 75% (amount of oxygen in the blood, normal greater than 92%), abnormally low. A tracheostomy tube was re-inserted and oxygen was administered at 60% via a tracheostomy mask and recovered.

Review of Patient #3's Nursing Care Plan indicated there was no documentation to support that his/her respiratory plan of care was updated to address the accidental decannulation on 10/10/20.

2. The Nursing Service failed to develop Patient #4's Nursing Care Plan after a heart transplant.

The Physician's Admission Hx and PE, dated 11/1/20, indicated Patient #4's assessment and plan included a primary problem of status post heart transplant with immunosuppressive medications, prophylactic antibiotics and daily monitoring of prograf (a medication to prevent the body's rejection of a transplanted organ) laboratory levels.

Review of Patient #4's Nursing Care Plan, indicated there was no documentation to support that a plan of care was developed for nursing care status post his/her heart transplant.

3. The Nursing Service failed to develop Patient #8's Nursing Care Plan, for end stage renal disease.

The Physician's Admission Hx and PE, dated 12/11/20, indicated Patient #8's assessment and plan included problems with end stage renal disease with hemodialysis treatments, and status post a suprapubic catheter insertion due to a neurogenic bladder.

Review of Patient #8's Nursing Care Plans indicated there was no documentation to support that a plan of care was developed for end stage renal disease or a suprapubic catheter.

During an interview on 12/1/20 at 3:30 P.M., the Quality Assurance Director said that the Nursing Care Plans for Patients #3, #4, and #8 were not developed or updated to address the patient's medical and nursing problems as per their policy.