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Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current an individualized comprehensive nursing care plan for each patient for 2 (#1, #5) of 6 current patients reviewed for nursing care plans from a total sample of 30 patients. Findings:

Review of the hospital policy titled Individual Plan of Care, Number PC 1002, revealed in part: To establish a comprehensive, goal oriented, individualized plan for each patient served based on assessment of patient physical, cognitive, behavioral communicative, emotional, pharmacological, pain management, and social needs. 2. The individual treatment plan includes the following information presently behavioral: c. The type of treatment and/or services to be provided, and revised when appropriate.

Patient #1
Review of the medical record for patient #1 revealed the patient was admitted to the hospital on 02/02/18. Further review of admission orders dated 02/02/18 revealed patient admitted to rehabilitation services for diagnosis of Stroke, CVA with left side hemiparesis, CHF, CAD, HTN, MI, and DM.

Review of the Initial nursing assessment completed on 02/02/18 included care plan goals and interventions for CVA, CHF, CAD, HTN, and MI but did not address goals or interventions for DM.

Interview on 02/14/18 at 2:20 p.m. with S3ADON confirmed there was no care plan documentation for goals and interventions for Diabetes for patient #1.


Patient #5
Review of the medical record for patient #5 revealed the patient was admitted to the hospital on 01/30/18. Further review of admission orders dated 01/30/18 revealed patient admitted to rehabilitation services for diagnosis of Muscle weakness, Decreased strength and Endurance, HTN, Schizophrenia disorder, Diabetic Neuropathy, and DM.

Review of the Initial nursing assessment completed on 02/02/18 included care plan goals and interventions for Muscle weakness, Decreased strength and Endurance, HTN, Schizophrenia disorder, but did not address goals or interventions for Diabetic Neuropathy, and DM.

Interview on 02/14/18 at 2:20 p.m. with S3ADON confirmed there was no care plan documentation for goals and interventions for Diabetes for patient #5.

Based on record review and interview, the hospital failed to ensure identified medication errors were documented in the patient's medical record for 1 (#7) of 2 (#7 and #8) hospital identified medication errors reviewed.

Findings:

Review of hospital's Policy and Procedure Manual revealed in part, the following: Pharmacy PH 2006 Drug Administration Error.
Policy: Drug administration errors are written when: Item #4. Drug is not given as it is ordered ... Procedure: When medication is administered improperly or a drug reaction occurs, the following procedure is used: Item # 4. Record incident ...in nurses' notes...

Review of the hospital's medication variance reports revealed patient #7 was ordered to receive Lisinopril 20 milligrams by mouth two times a day but only received the medication once a day.

During an interview on 2/15/18 at 10:25 a.m. S3ADON confirmed, after review of patient #7's medical record, the medication error was not documented in the patient's medical record.