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Based on record review and interview the facility failed to ensure that a comprehensive care plan that is individualized, and based on assessing the patient's nursing care needs, treatment goals, admitting diagnosis', has current, appropriate nursing interventions with ongoing assessments of patient's needs and response to interventions. In 8 of a total of 10 medical records reviewed (Patient #'s 1, 2, 4, 5, 7, 8, 9, & 10)

Findings include:

The facility policy titled "Nursing Care Plan" #NO2-N dated 4/17 was reviewed on 4/11/19 at 11:25 AM. This document revealed on page 1 item #5 "Each discipline develops a plan of care. Short-term goals shall be established based on daily assessment findings and each discipline shall be responsible to review these goals and progress with patient and approved significant others. The overall care and progress is reviewed and care plans adjusted based on daily assessments and the Interdisciplinary Team Meeting outcomes. 6. The key issues that Nursing has primary responsibility for in the CCIS (Chronically Critically Ill) patient include: a. Assessment and management of delirium. b. Prevention and early recognition of sepsis. c. Safety and prevention of in-hospital injury. d. Mobility plan. e. Wound Prevention and management. f. Management of discomfort and pain. Procedure: 1. Nursing care planning begins with the assessment of the patient at the time of admission, with attention to the key issues assigned to Nursing related to CCIS. On the 24 Hour Patient Record and Plan of Care form the nurse will implement and document approaches related to key nursing care issues and establish short term goals based on the nursing assessment findings." The policy on page 3 continues to list "Care Guidelines" and "Problems and Approach" including Malnutrition: Protein Wasting, Calorie Deficiency, Bone loss, Glycemic Control, Management and Protection from Infection, Myopathy of Critical Illness, Wounds, Delirium/depression and Symptom Burden and Suffering. On page 3 under "Glycemic Control" states "1. A clear plan to manage needs to be established. 2. Meticulous follow-through with management strategy needs to happen. 3. Interruptions in feeding must be considered before insulin administration. 4. Daily assessment of changing needs as CCIS resolves, insulin supplement needs should decrease." On page 4 under "Wounds: 1. Follow Wound Prevention Policy. 2. Float heels consistently and implement cushion program. 3. Mobility including turns, OOB (out of bed), ROM (range of motion). Follow the "Rule of 30". 4. Prevent and manage moisture associated skin damage. 5. Adequate, consistent nutrition. 7. Wound care protocols for existing wounds."

The facility policy titled "Restraints and Seclusion" #R02-N dated 10/18 reviewed on 4/11/19 at 12:00 PM. This document revealed on page 8 under "MEDICAL RECORD DOCUMENTATION AND PLAN OF CARE: Modification of the patient's treatment plan related to restraint use, patient's response to restraint, and plan for reduction/elimination is included in the patient's medical record. Interdisciplinary Team Member documentation must: State plan of care (at implementation & q (every) day)."

Patient #2's medical record was reviewed on 4/11/19 at 9:50 AM. Patient #2 was a 76 year old admitted to the facility on 3/20/19 and is an inpatient currently who was admitted with diagnosis' of intraventricular hemorrhage requiring surgical evacuation of a hematoma, AVM (arterial vascular malformation in the brain), aspiration pneumonia, tracheostomy (stoma into trachea)placement and mechanical ventilation and receiving gastro enteral tube feeding nutrition receiving nothing by mouth. Patient #2 upon admission was pulling at tracheostomy and medical lines and was put in bilateral wrist restraints.

Patient #2's "Plan of Care" last reviewed on 4/10/19 at 10:43 PM by Registered Nurse L documented the following problems, goals and outcomes: "1. Infection. Absence of infection and prevention of transmission during hospitalizations. Progressing. 2. Fall Safety. Free from fall injury. Progressing. 3. Knowledge Deficit. Patient and/or family demonstrate readiness to learn. Progressing. 4. Discharge Planning. Discharge to home or other facility with appropriate resources. Progressing. 5. Potential for Compromised Skin Integrity. Skin integrity is maintained or improved. Progressing. 6. Urinary Incontinence. Perineal skin integrity is maintained or improved. Progressing. 7. Bowel Incontinence. Perineal skin Integrity is Maintained or Improved. Progressing. 8. Pain. Patient's pain/discomfort is manageable. Progressing."

There was no documented nursing interventions addressed for any of the above listed problems. There was no documented care plan problem for wrist restraints or gastro enteral tube feedings.

Patient #7's medical record was reviewed on 4/11/19 at 12:05 PM. Patient #7 was a 49 year old admitted to the facility on 3/27/19 with admitting diagnosis' of Endocarditis (infection in the lining of the heart)and heart valve disorders, a drain present to abdominal abscess, Type 2 Diabetes Mellitus (receiving insulin injections three times a day), Hypertension (elevated blood pressure), abdominal abscess, Chronic Obstructive Pulmonary Disease (obstructive lung disease), sleep apnea, implanted cardiac defibrillator, non traumatic splenic rupture, severe protein-calorie malnutrition and anemia (low red blood cell count).

Patient # 7's "Plan of Care" last reviewed on 4/10/19 at 7:35 PM by Registered Nurse J documented the following problems, goals and outcomes: "1. Infection. Absence of infection and prevention or transmission during hospitalization. progressing. 2. Fall Safety. Free from fall injury. Progressing, 3. Knowledge Deficit. Patient and/or family demonstrate readiness to learn. Progressing. 4. Discharge planning. Discharge to home or other facility with appropriate resources, Progressing. Care giver will develop a plan to decrease their burden and enhance comfort in role. Progressing. 5. Knowledge Deficit. Patient/family/caregiver demonstrates understanding of disease process, treatment plan, medications, and discharge instructions, Progressing. 6. Potential for Compromised Skin Integrity. Skin integrity is maintained or improved. Progressing. Goal: Nutritional status is improving. Progressing. 7. Urinary Incontinence. Perineal skin integrity is maintained or improved. Progressing. 8. Bowel Incontinence. Perineal Skin Integrity is Maintained or Improved. Progressing. 9. Pain. Patient's pain/discomfort is manageable. Progressing. 10. Case Management Discharge Goals. Identify patient's discharge goals. Progressing. Coordinate safe discharge plan. Progressing."

There were no documented nursing interventions or measurable goals based on current nursing assessment and delivered nursing cares addressed for any of the above listed problems. There was no documented care plan problem for Patient # 7's insulin dependent diabetes, severe protein-calorie malnutrition or abdominal drain.

Patient #8's medical record was reviewed on 4/11/19 at 1:45 PM. Patient #8 was a 50 year old admitted to the facility on 2/15/19 and discharged on 3/1/19 with admitting diagnosis' of endocarditis, fluid restrictions, kidney disease, diabetes mellitus, hypertension, pacemaker, left lower leg below the knee amputation, group B streptococcus bacteremia from an infected pacemaker pocket on the right upper chest and a PICC (peripheral central intravenous line) in the right upper arm for antibiotic infusions. That infected pacemaker was surgically removed on 2/6/19 and a temporary pacemaker wires placed until infection was gone and a permanent one could be replaced. During the hospitalization prior to admission to the facility Patient #8 had altered mental status which had been determined to be secondary to septic emboli to the brain related to endocarditis. On admission Patient #8 had wounds on buttocks and right foot (a total of 5 areas) on admission to facility.

Patient #8's "Plan of Care" last reviewed on 2/28/19 at 11:40 PM by Registered Nurse N documented the following problems, goals and outcomes: "1. Infection. Absence of Infection and Prevention of Transmission during hospitalization. Progressing. 2. Fall Safety. Free from fall injury. Progressing. 3. Knowledge Deficit. Patient and/or family demonstrate readiness to learn. Patient and/or family verbalizes understanding of education and/or performs desired skill. Progressing. 4. Discharge Planning. Discharge to home or other facility with appropriate resources. Progressing. 5. Knowledge Deficit. Patient and/or family demonstrate readiness to learn. Progressing. 6. Risk for compromised skin integrity. Skin integrity is maintained or improved. Progressing. 7. Insufficient Nutritional Intake. Nutritional status is stable/improving. Progressing. 8. Risk for inadequate nutritional intake for needs. Maintains adequate nutritional intake. Progressing. 9. Risk for Deficient Fluid Volume. Fluid and electrolyte balance are achieved/maintained. Progressing. 10. Potential for infection. Absence of infection and prevention of transmission during hospitalization. Progressing. 11. Risk for Impaired Sensory Perception. Patient remains free of injury or trauma. Progressing. 12. Potential for Compromised Skin Integrity. Skin integrity is maintained or improved. Progressing. 13. Urinary Incontinence. Perineal skin integrity is maintained or improved. Progressing. 14. Bowel Incontinence. Perineal Skin Integrity is Maintained or Improved. Progressing. 15. Malnutrition. Patient will perform feeding tasks with supervision. Progressing. 16. Pain. Patient's pain/discomfort is manageable. Progressing."

There were no documented nursing interventions or measurable goals based on current nursing assessment and delivered nursing cares addressed for any of the above listed problems. There was no documented care plan problem for Patient #8's fluid restrictions, PICC line or open wounds being treated at facility.

Patient #9's medical record was reviewed on 4/11/19 at 9:50 AM. Patient #9 was a 50 year old admitted to the facility on 1/3/19 and discharged 1/25/19 with admitting diagnosis' of bacteremia, hypertension, fluid restriction, pulmonary embolism, non-ischemic cardiomyopathy, aortic valve and stenosis, polysubstance abuse, pulmonary embolism, and infected periodontal abscesses.

Patient #9's "Plan of Care" last reviewed on 1/25/19 at 2:10 AM by Registered Nurse M documented the following problems, goals and outcomes: "1. Infection. Absence of infection and prevention of transmission during hospitalization. Progressing. 2. Knowledge Deficit. Patient and/or family demonstrate readiness to learn. Progressing. 3. Discharge Planning. Discharge to home or other facility with appropriate resources. Progressing. 4. Knowledge Deficit. Patient/family/caregiver demonstrates understanding of disease process, treatment plan, medications, and discharge instructions. Progressing. 5. Potential for Compromised Skin Integrity. Skin integrity is maintained or improved. Progressing. 6. Pain. Patient's pain/discomfort is manageable. Progressing. 7. Fall. Free from fall injury. Progressing. 8. Urinary incontinence. Perineal skin integrity is maintained or improved. Progressing. 9. Bowel Incontinence. Perineal Skin Integrity is Maintained or improved. Progressing"

There were no documented nursing interventions or measurable goals based on current nursing assessment and delivered nursing cares addressed for any of the above listed problems. There was no documented care plan problem for Patient #9's fluid restriction.

Patient #10's medical record was reviewed on 4/11/19 at 11:45 AM. Patient #10 was a 64 year old admitted to the facility on 2/1/19 and is currently an inpatient with admitting diagnosis' of osteomylitis (infection of the bone), acute respiratory failure post pneumonia, decubitus ulcer on buttocks and wounds on bilateral feet (11 areas total) and insulin dependent Diabetes Mellitus.

Patient #10's "Plan of Care" last reviewed on 4/9/19 at 2:44 PM by Registered Nurse K documented the following care plan problems, goal and outcomes: "1. Knowledge Deficit. Patient/family/caregiver demonstrates understanding of disease process, treatment plan, medications and discharge instructions. Progressing. 2. Potential for Compromised Skin Integrity. Skin integrity is maintained or improved. Progressing. 3. Nutritional status is improving. Progressing."

There were no documented nursing interventions or measurable goals based on current nursing assessment and delivered nursing cares addressed for any of the above listed care plan problems. There was no documented care plan problem for Patient #10's wound care of 11 open areas or insulin dependent diabetes.

The above findings were confirmed at the time of record review with Registered Nurse G.




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Findings include:

Patient #1's medical record was reviewed on 4/11/2019 at 11:08 AM. Patient #1, the complainant, was a 65 year old admitted to the facility on 12/27/2018 and discharged on 2/1/2019 with admitting diagnosis including septic endocarditis (inflammation of the valve of the heart), anemia of chronic disease, bacteremia due to staphylococcus aureus, toxic metabolic encephalopathy (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function), obstructive sleep apnea syndrome, acute renal failure with dialysis, intracranial septic embolism (the result of an infection in one part of the body that migrates to another), deep vein thrombosis, respiratory failure with tracheostomy, and hypertension (high blood pressure). Patient had a PICC(peripherally inserted central catheter) line for antibiotics and a past medical history of diabetes mellitus.

Patient #1's "Plan of Care" last reviewed on 1/31/2019 at 11:20 PM by Registered Nurse M documented the following problems, goals and outcomes: 1. Infection. Absence of infection and prevention of transmission during hospitalization. Progressing. 2. Fall Safety. Free from fall. Progressing. 3. Knowledge Deficit. Patient and/or family demonstrate readiness to learn. Progressing. Patient and/or family verbalizes understanding of education, and/or performs desired skill. Progressing. 4. Discharge Planning. Discharge to home or other facility with appropriate resources. Progressing. Care giver will develop a plan to decrease their burden and enhance comfort in role. Progressing. 5. Pain. Patient's pain/discomfort is manageable. Progressing. 6. Potential for Compromised Skin Integrity. Skin integrity is maintained or improved. Progressing. Nutritional status is improving. Progressing. 7. Urinary incontinence. Perineal skin integrity is maintained or improved. Progressing. 9. Bowel Incontinence. Perineal Skin Integrity is Maintained or improved. Progressing"

There were no documented nursing interventions or measurable goals based on current nursing assessment and delivered nursing cares addressed for any of the above listed problems. There was no documented care plan problem for Patient #1's obstructive sleep apnea, diabetes mellitus, PICC line or tracheostomy care.

Patient # 4's medical record was reviewed on 4/11/2019 at 10:18 AM. Patient #4 was a 71 year old admitted to the facility on 11/24/2018 and discharged on 4/2/2019 with admitting diagnosis including sepsis due to discitis seeded from left foot ulcers to back, thrombocytopenia (deficiency of platelets in the blood), severe lumbar pain, and insulin dependent diabetes mellitus.

Patient #4's "Plan of Care" last reviewed on 4/2/2019 at 3:37 PM by Registered Nurse N documented the following problems, goals and outcomes. All Outcomes are dated 4/2/2019: 1. Infection. Absence of infection and prevention of transmission during hospitalization. Outcomes: Completed. Adequate for Discharge. Progressing. 2. Fall Safety. Free from fall. Outcomes: Completed. Adequate for Discharge. Progressing. 3. Knowledge Deficit. Patient and/or family demonstrate readiness to learn. Outcomes: Completed. Adequate for Discharge. Progressing. Patient and/or family verbalizes understanding of education, and/or performs desired skill. Outcomes: Completed. Adequate for Discharge. Progressing. 4. Discharge Planning. Discharge to home or other facility with appropriate resources. Outcomes: Completed. Adequate for Discharge. Not Progressing. Care giver will develop a plan to decrease their burden and enhance comfort in role. Outcomes: Completed. Adequate for Discharge. Not Progressing. 5. Pain. Patient's pain/discomfort is manageable. Outcomes: Completed. Adequate for Discharge. Progressing. 6. Knowledge Deficit. Patient/family/ caregiver demonstrates understanding of disease process, treatment plan, medications and discharge instructions. Outcomes: Completed. Adequate for Discharge. Progressing 6. Potential for Compromised Skin Integrity. Skin integrity is maintained or improved. Outcomes: Completed. Adequate for Discharge. Progressing. Nutritional status is improving. Completed. 8. Urinary incontinence. Perineal skin integrity is maintained or improved. Outcomes: Completed. Adequate for Discharge. Progressing. 9. Bowel Incontinence. Perineal Skin Integrity is Maintained or improved. Outcomes: Completed. Adequate for Discharge. Progressing. 10. Case Management Discharge Goals. Identify patient's discharge goals. Outcomes: Completed. Adequate for Discharge. Progressing. Coordinate safe discharge plan. Outcomes: Completed. Adequate for Discharge. Not Progressing.

There were no documented nursing interventions or measurable goals met based on current nursing assessment and delivered nursing cares addressed for all but the nutritional status improvement of the above listed problems. There was no documented care plan for Patient #4's wound care or diabetes mellitus.

Patient #5's medical record was reviewed on 4/11/2019 at 11:55 AM. Patient #4 was a 41 year old admitted to the facility on 2/25/2019 and discharged on 4/8/2019 with admitting diagnosis of traumatic brain injury, intracranial hemorrhage (bleeding in the brain), acute seizures, past pituitary adenoma with cranioplasty/scalp flap with chronic open left scalp wound, chronic opioid dependence, respiratory failure, partial blindness, and insulin dependent diabetes mellitus. She was non-verbal and had a tracheostomy and a feeding tube.

Patient #5's "Plan of Care" last reviewed on 4/8/2019 at 8:44 AM by Registered Nurse O documented the following problems, goals and outcomes. All Outcomes are dated 4/8/2019: 1. Infection. Absence of infection and prevention of transmission during hospitalization. Outcomes: Completed. Progressing. 2. Fall Safety. Free from fall. Outcomes: Completed. Progressing. 3. Knowledge Deficit. Patient and/or family demonstrate readiness to learn. Outcomes: Completed. Progressing. Patient and/or family verbalizes understanding of education, and/or performs desired skill. Outcomes: Completed. Progressing. 4. Discharge Planning. Discharge to home or other facility with appropriate resources. Outcomes: Completed. Progressing. Care giver will develop a plan to decrease their burden and enhance comfort in role. Outcomes: Completed. Progressing. 5. Knowledge Deficit. Patient/family/ caregiver demonstrates understanding of disease process, treatment plan, medications and discharge instructions. Outcomes: Completed. Progressing. 6. Potential for Compromised Skin Integrity. Skin integrity is maintained or improved. Outcomes: Completed. Progressing. Nutritional status is improving. Completed. Progressing. 7. Urinary incontinence. Perineal skin integrity is maintained or improved. Outcomes: Completed. Progressing. 8. Bowel Incontinence. Perineal Skin Integrity is Maintained or improved. Outcomes: Completed. Progressing. 9. Knowledge Deficit. Patient and/or family demonstrate readiness to learn. Outcomes: Completed. Progressing. Patient and/or family verbalizes understanding of education, and/or performs desired skill. Outcomes: Completed. Progressing. 10. Risk for/impaired spontaneous ventilation;risk for ineffective breathing pattern. Patient will maintain adequate air exchange; patient will maintain or improve breathing pattern. Outcomes: Completed. Progressing. Patient will maintain clear, open airways. Outcomes: Completed. Progressing. 11. Risk for ineffective airway clearance. Patient will maintain clear, open airways. Outcomes: Completed. Progressing. 12. Risk for aspiration. Patient is free of signs of aspiration and the risk of aspiration is decreased. Outcomes: Completed. Progressing. 12. Risk for /Altered hemodynamic status. Patient has stable or improving hemodynamic status. Outcomes: Completed. Progressing. 13. Risk for impaired skin integrity. Skin integrity is maintained or improved. Outcomes: Completed. Progressing. 14. Risk for impaired mobility (activity intolerance). Mobility/activity is maintained at optimum level for patient. Outcomes: Completed. Progressing. 15. Risk for imbalanced nutrition. Maintains adequate nutritional intake. Outcomes: Completed. Progressing. 16. Risk for impaired communication. Establish communication to meet the patient/caregiver needs. Outcomes: Completed. Progressing. 17. Risk for impaired cognition. Patient has stable or improving condition. Outcomes: Completed. Progressing. 18. Risk for infection. Absence of infection and prevention of transmission during hospitalization. Outcomes: Completed. Progressing. Risk for anxiety. Demonstrates ability to cope effectively. Outcomes: Completed. Progressing. 18. Pain. Patient's pain/discomfort is manageable. Outcomes: Completed. Progressing. 19. Case Management Discharge Goals. Identify patient's discharge goals. Outcomes: Completed. Progressing. Coordinate safe discharge plan. Outcomes: Completed. Progressing.

There were no documented nursing interventions or measurable goals met based on current nursing assessment and delivered nursing cares addressed for all but the nutritional status improvement of the above listed problems. There was no documented care plan for Patient #4's wound care, seizure disorder, care of feeding tube or tracheostomy, or diabetes mellitus.

The above findings were confirmed on 4/11/2019 at the conclusion of each record review with an interview with Registered Nurse I.