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Based on review of records and interview, the Registered Nurse (RN, Personnel #4) did not evaluate the nursing care for 1 of 1 patient (Patient #1) who was hospitalized from 02/25/11 through 04/14/11 and had increased bowel movements (BM's) on 04/13/11. The RN (Personnel #4) did not administer Lomotil to Patient #1 as directed by the physician's 03/24/11 order. This practice could present the risk of potential harm to Patient #1.

Findings included:

Patient #1, age 42, was admitted to the hospital on 02/25/11 for "respiratory failure, recurrent pneumonia, and ICU (intensive care unit) support." The "History and Physical" dated 02/25/11 noted, "brainstem encephalitis...taken care of by her parents...high level of functioning...cannot walk... " Treatment included tube feedings, pulmonary support, and antibiotics.

On 03/24/11, the physician's order was received for "Lomotil" as needed for loose stools not to exceed 8 tablets in one day.

The 04/08/11 "Laboratory Services" report for "Clostridium difficile Toxins A and B (C.diff A/B)" stool test indicated "negative...dark green... mucoid." Patient #1 had 2 BM's per the "Vital Signs and Intake & Output Records" and 3 BM's on 04/09/11.

The 04/10/11 C.diff A/B stool test indicated "negative...dark green...watery." Patient #1 had one BM per the "Vital Signs and Intake & Output Records."

The 04/11/11 C.diff A/B stool test indicated "negative...green...mucoid." Patient #1 had 2 BM's per the "Vital Signs and Intake & Output Records."

On 04/12/11, the "Vital Signs and Intake & Output Records" indicated Patient #1 had 2 BM's. The "Daily Nursing Assessment" indicated Patient #1's stool characteristics as liquid and brown. At 09:00 AM, Patient #1 was cleaned after a "large loose brown BM."

On 04/13/11 at 10:00 AM, the "Nurses Notes" from the "Daily Nursing Assessment" indicated that Patient #1 had a BM. Monitoring was continued. At 11:00 AM, a BM was cleaned by the technician. At 11:35 AM, a BM was cleaned by the technician and bath technician. At 01:30 PM, a BM was cleaned by a technician. At 05:05 PM, Patient #1 had another bowel movement. The 7:00 AM - 7:00 PM "Daily Nursing Assessment" indicated Patient #1 had mushy black to dark green stools.

Patient #1's "Vital Signs and Intake & Output Records" dated 04/13/11 indicated Patient #1 had 7 BM's. The medication documentation did not include that Lomotil was administered according to the physician's 03/24/11 order.

During an interview on 06/08/11 at approximately 11:00 AM, the Registered Nurse who cared for Patient #1 on 04/13/11 (Personnel #4) reviewed Patient #1's medical record with the surveyor and was asked if she had administered Lomotil on 04/13/11 according to the physician's order of 03/24/11. Personnel #4 said that she remembered checking about the "C-diff " results, but did not remember why the Lomotil was not given.

The "Administration of Drugs" policy #130-28-002.4 revised by the hospital January 2009 included the following information: "Drugs shall be administered to patients only upon the receipt of the order from an authorized prescriber...administered by...appropriately licensed personnel...should be administered according to the order and in consideration of good nursing practice..."

Based on review of records and interview, the hospital failed to ensure that the nursing staff kept current a nursing care plan for 1 of 1 patient (Patient #1) who was hospitalized from 02/25/11 and on 04/13/11 had a change in condition of increased bowel movements (BM's). This practice could present the risk of potential harm to Patient #1.

Findings included:

Patient #1, age 42, was admitted to the hospital on 02/25/11 for "respiratory failure, recurrent pneumonia, and ICU (intensive care unit) support." The "History and Physical" dated 02/25/11 noted, "brainstem encephalitis...taken care of by her parents...high level of functioning...cannot walk... " Treatment included tube feedings, pulmonary support, and antibiotics.

The 04/08/11 "Laboratory Services" report for "Clostridium difficile Toxins A and B (C.diff A/B)" stool test indicated "negative...dark green... mucoid." Patient #1 had 2 BM's per the "Vital Signs and Intake & Output Records" and 3 BM's on 04/09/11.

The 04/10/11 C.diff A/B stool test indicated "negative...dark green...watery." Patient #1 had one BM per the "Vital Signs and Intake & Output Records."

The 04/11/11 C.diff A/B stool test indicated "negative...green...mucoid." Patient #1 had 2 BM's per the "Vital Signs and Intake & Output Records."

On 04/12/11, the "Vital Signs and Intake & Output Records" indicated Patient #1 had 2 BM's. The "Daily Nursing Assessment" indicated Patient #1's stool characteristics as liquid and brown. At 09:00 AM, Patient #1 was cleaned after a "large loose brown BM."

Patient #1's "Transdisciplinary Plan of Care" noted a bowel problem was initiated 03/27/11. A flexi seal tube was inserted on 03/26/11 and the bowel problem was active as of 03/27/11. The 03/31/11 "Transdisciplinary Plan of Care" evaluation note indicated, "loose stools extremely, flexi seal difficulty staying intact, out for now..." The care plan was reviewed 04/01/11, 04/02/11, 04/04/11, 04/05/11, 04/07/11, and 04/12/11 without an update to Patient #1's bowel problem.

On 04/13/11 at 10:00 AM, the "Nurses Notes" from the "Daily Nursing Assessment" indicated that Patient #1 had a BM. Monitoring was continued. At 11:00 AM, a BM was cleaned by the technician. At 11:35 AM, a BM was cleaned by the technician and bath technician. At 01:30 PM, a BM was cleaned by a technician. At 05:05 PM, Patient #1 had another bowel movement. The 7:00 AM - 7:00 PM "Daily Nursing Assessment" indicated Patient #1 had mushy black to dark green stools.

Patient #1's "Vital Signs and Intake & Output Records" dated 04/13/11 indicated Patient #1 had 7 BM's. The nursing care plan was not reviewed and updated on 04/13/11 or 04/14/11 as to the increased bowel movements/change in condition of Patient #1 on 04/13/11.

During an interview on 06/08/11 at approximately 11:00 AM, the Registered Nurse who cared for Patient #1 on 04/13/11 (Personnel #4) reviewed Patient #1's medical record with the surveyor and agreed that Patient #1 had a change in condition with the increased bowel movements to 7 on 04/13/11 and that the care plan was not updated to reflect this change in condition.

The "Transdisciplinary Care Planning" policy #021-24-001.1 revised by the hospital July 2005 included the following information: "Based on prioritization of patient care needs identified, an appropriate care plan will be initiated by the RN...Interventions will be chosen and/or developed to aid in achievement of goals...New goals and target dates and interventions for those goals will be set as appropriate..."