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Based on observation, interview and record review, the facility failed to ensure that registered nurses adhered to facility's policy and procedures regarding patients' timely initiation and documentation of the plan of care for three patients (P-1, 2 and 3) of 3 patients reviewed, resulting in possible unidentified patient care needs for these patients. Findings include:

P-1
Review of the P-1 medical record revealed that patient was an 88-year-old female presented to facility's emergency department (ED) on 03/11/25 at 1840 with a chief complaint of weakness.
On 03/11/25 at 1842 a fall risk assessment was completed with a total Kinder score of 1 (The Kinder Falls Risk Assessment Tool utilizes five screening questions to identify those at risk of falling. A positive response to any of the questions denotes the requirement for risk reduction interventions to be implemented).

On 03/11/25 at 1938 patient was "roomed" in RD401H. At approximately 2245 on 03/11/25 P-1 suffered a fall in the bathroom. P-1 was assigned a room RD 407 at 2246. On 03/11/25 at 2255 she was placed in observation status. On 03/12/25 at 0322 P-1's status was changed to inpatient, and she was transferred to an inpatient unit.

Further review of the record indicated that no nursing-initiated Care Plan Guide (CPG) was documented for P-1 during her stay in the facility's ED and further, patient's care plan was not evaluated by ED nursing staff at disposition/departure from the ED considering she suffered a fall with a hip fracture while in the facility's ED.

P-2
Review of the P-2 medical record revealed that P-2 was a 66-year-old female who arrived at facility's ED on 05/06/25 at 1642 with a chief complaint of shortness of breath (wears 3L (liters of Oxygen) at baseline SpO2 86% (Oxygen saturation), now on 6L SpO2 94%, positive for cough and lower left extremity cellulitis. Symptoms worse with movement, patient was treated for pneumonia a week prior).
Fall risk assessment was completed on 05/06/25 at 1652 with a Kinder score of 2.

Physician's note dated 05/06/25 2146 revealed: "Interventions initiated while patient (P-2) was in the ED (emergency department) included Cefazolin, Vancomycin, Zithromax, Ceftriaxone (antibiotics). Patient's lab and imaging findings significant for pneumonia. Unlikely CHF (congestive heart failure) exacerbation as BNP negative (B-type natriuretic peptide is a diagnostic blood test that can indicate worsening heart failure). Discussed case with admitting physician who agreed with plan of admission to progressive care unit for further care and evaluation. Consults to Cardiology and Pulmonology were placed. Lasix was not ordered in the setting of possible AKI (acute kidney injury) which is likely from over diuresis."

On 05/06/25 at 1707 patient was assigned room BL508 and a nurse was assigned as well.
On 05/06/25 at 2126 order was placed to admit P-1 to inpatient.
On 05/07/25 at 0913 Shortness of breath assessments were completed by the nurse, and at 0914 "Asthma Exacerbation CPG Interventions" were initiated. At 0915 "General Emergency Care CPG Interventions", "Dyspnea or Respiratory Distress CPG Interventions" and "COPD Exacerbation CPG Interventions" were added (16 hours after P-1 was assigned the bed in ED).

P-3
Review of the P-3 medical record revealed that P-3 was an 83-year-old male presented to facility's emergency department (ED) on 05/07/25 at 0908 with a chief complaint of "knee pain (Fall from standing. Was standing at sink washing hands when he states [sic] "my knees just gave out" denies any lightheadedness, dizziness, syncope, LOC (loss of consciousness). Complaints of left knee pain. Pain controlled at rest, significant with movement)".

P-3 was observed on 05/07/25 at 1000 lying on a stretcher in ED. His wife was sitting at the bedside. P-3 was interviewed during observation and stated that he was just admitted here because he fell at home. Patient was asked if staff nurses educated him to call for help when needed and not to get up on his own. P-3 stated that "they don't need to remind me, I know that". Registered nurse assigned to care for P-3, Staff K, approached the stretcher and applied yellow socks and a yellow wrist band to the patient. No education/reminder was provided to the patient and the family while she was doing that why he needed to wear those.

Further review of the P-3 medical record on 05/07/25 at approximately 1430 revealed that a fall risk assessment was completed on 05/07/25 at 0921 with a Kinder score of 3.

Patient was assigned room RD406H on 05/07/25 at 0933. Patient's status changed to "ED observation patient" at 1218. At 1238 he was transferred to room RD403.

"Lower Extremity Injury CPG Interventions" were initiated by the nurse, Staff K, on 05/07/25 at 1510.

On 05/07/25 at 1512 during the interview with ED Nurse Manager, Staff J, she was asked about her expectations on how soon nurses need to chart on the patients' assessments and plan of care. She stated that nurses need to provide patients' assessments and care first, address any emergency needs, IV (peripheral intravenous access) starts, labs, tests, orders and then timely document the tasks completed including the care plan (CPG).

Facility's policy "Patient Plan of Care", effective 07/21/24, was reviewed on 05/07/25 and revealed:
"I. Purpose
To establish guidelines to provide an individualized plan of care for each patient that is interprofessional, coordinated, high quality, and both patient and family-centered within the acute care setting (inpatient, ED and surgical/procedural care spaces).

III. Policy
A. Plan of Care Principles:
i. Each patient will have a plan of care that is appropriate to their unique needs. It begins on arrival in the Emergency Department (ED), admission to the hospital and/or surgical/procedural setting.
iii. Planning care starts with learning the patient's chief complaint or medical diagnosis, assessment findings, and results of diagnostic testing to determine their individual needs.
iv. Evidence-based Care Plan Guides (CPG(s)) and supportive documentation tools are designed for specific care settings and formulate the patient plan of care. CPGs support the associated professional processes of care (e.g., focused, and ongoing assessments, implementation of interventions to prevent/manage potential problems, goal/outcome evaluation, suggested patient education topics). Alterations or deviations from the evidence-based CPGs may be appropriate according to patient preference, provider order(s) or facility policy/procedure.
v. The patient plan of care is individualized/revised based on ongoing assessment findings, the patient's response to treatment/interventions and evaluation of progress toward goals/outcomes.

B. Emergency Department Plan of Care:
i. The patient care plan is initiated as soon as enough information is available to select appropriate Care Plan Guide (CPG), and within thirty minutes of ED bed assignment.
a. A "rule-out" diagnosis may be used as the basis for selecting CPGs.
ii. The patient's care plan is evaluated at disposition/departure from the ED."