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Based on review of records and interviews, the facility failed to develop and keep current nursing care plans to address the patients' needs for 6 of 6 patients (citing patients # 2, 3, 4, 5, 6, and 7)

Findings:

Record review of a policy titled " Admission Assessment and Ongoing Reassessment of Patients " (dated 2/07) stated the information gathered from the admission assessment and subsequent reassessment of the patient will be utilized to plan the patient ' s care and to identify education and discharge planning needs for the patient. The policy further stated the RN will transfer patient problems identified to the Interdisciplinary Treatment Plan as the initiation of the patient ' s plan of care.

Record review of a policy titled " Care Plan: Nursing " (dated 2/07) stated a registered nurse will formulate and initiate the plan of care within twenty-four hours of admission. A Registered Nurse will review the plan of care and evaluate planned interventions on a daily basis with revision(s) as indicated. The nurse will utilize the plan of care as a tool for documentation. Planning, and evaluating nursing interventions directed toward resolution of identified problems. The plan of care will address the disease process, social, psychosocial, rehabilitative, safety, and educational needs of the patient.

Chart review of patient # 6 revealed she was admitted on 7/27/10 with diagnoses of sepsis, Urinary Tract Infection (UTI), Acute Renal Failure, Dysphasia, and Malnutrition. The patient also had lower extremity gangrene and sacral skin break down. The patient ' s initial care plan was dated 8/20/10 and did not reflect this patient ' s current medical problem. There was no updated care plan found in the record but there was daily documentation of teaching provided to the patient by the nurses.
Interview with the Director of Nursing (DON)(# 52) revealed there should be an updated care plan but he was unable to find one. The facility care plan had check-off boxes for various medical problems but not all the areas involving this patient were checked nor addressed. The DON could not explain why this patient ' s plan of care was not initiated until 8/20/10, 25 days after admission.

Chart review of patient # 7 revealed he was admitted on 8/31/10 with the diagnoses of GERD (Gastro esophageal reflux disease), COPD (chronic obstructive pulmonary disease), and Asthma. He was receiving nebulizer treatments, blood pressure medication, and medication for elevated blood sugar. The patient was on a special diet: 2 gram sodium, low fat, and low cholesterol. This patient ' s plan of care did not address his nutritional problems or his diabetes.

Chart review of patient # 2 revealed he was admitted 7/7/10 with the diagnosis of status post transmetatarsal/amputation right 2nd and 3rd toes with flap. The patient also had skin breakdown at the right lateral abdominal area, coccyx, scrotum, and right foot and was having his blood glucose level checked three times a day. His care plan addressed skin integrity, mobility intolerance, and potential for infection but did not address his comfort/pain, nutritional needs, or education needs.

Chart review of patient # 3 revealed he was admitted on 8/13/10 for and infected left foot ulcer with MRSA. The following problems were checked on the care plan: tissue perfusion, sensory perception, comfort/pain, nutrition, skin integrity, mobility activity intolerance, and potential for infection. Although multiple problems were identified, no interventions were checked.

Chart review of patient # 4 revealed he was admitted on 8/5/10 with the diagnoses of sepsis and right foot abscess. The following problems were identified 8/5/10 on the care plan form: tissue perfusion, sensory perception, comfort/pain, skin integrity, mobility intolerance, and potential for infection. There was no review of the care plan to date of the survey.

Chart review of patient # 5 revealed she was admitted on 7/19/10 with a diagnosis of failure to thrive. There was no date on the initial care plan. The following problems were identified: Tissue perfusion, sensory perception, comfort/pain, fluid balance/electrolyte balance, nutrition, skin integrity, mobility intolerance, potential for infection, and elimination. There were interventions checked for the problem of tissue perfusion, but none of the other problems had any interventions checked.