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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 appropriate nursing interventions with ongoing assessments of patient's needs and response to interventions. In 9 of 10 in a total universe of 10 (1, 2, 3, 4, 5, 7, 8, 9 & 10) medical records reviewed.

Findings include:

The facility policy titled "Nursing Care Plan" #NO2-N dated 4/17 reviewed 11/14/17 at 10:25 AM page 2 under "Procedure" #2 "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. 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 (Chronic Critically Ill) resolves, insulin supplement needs should decrease."

Patient #1's medical record was reviewed on 11/14/17 at 10:40 AM. Patient #1's "Admission History & Physical" revealed patient was admitted on 8/25/17 with admitting diagnosis of Chronic Obstructive Pulmonary Disease with respiratory failure requiring a tracheotomy (stoma into trachea to assist with breathing) and mechanical ventilation assistance (admitted on ventilator weaned to just requiring assistance at bedtime while in hospital), Abdominal Aorta Aneurysm repair with an endovascular leak and graft placement 6/17, right groin incisional wound with flap requiring a wound vac, asystole (heart stopped) requiring pacemaker placement 7/17, left sided pleural effusion (collection of fluid on lung) requiring thoracentesis twice (aspiration of fluid with a needle into chest) and chest tube placement (tube placed into chest to provide constant suction to keep lung inflated and drain fluid) 9/19/17-10/6/17, right lung pneumothorax requiring chest tube (tube into pleural space to remove fluid and keep lung inflated) 8/11/17-8/16/17, sacral decubitus ulcer, fevers, dysphagia (difficulty swallowing) requiring enteral feedings (tube feedings directly into stomach), urinary tract infection, fevers, and debilitation. On admission Patient #1 was physically very weak and only able to sit on the side of bed and was very unsteady.

Upon review of Patient #1's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" and supplemental "PLAN OF CARE" (supplemental care plan to 24 hour flowsheet) for dates 10/9-10/2/17 active care plan problems included the following: Alteration in comfort (pain), Alteration in sensory perception, Alteration in tissue perfusion, Alteration in sleep, Potential for harm/injury related to removal of medical devices (patient removed tracheotomy on 9/1/17), Alteration in skin integrity (right groin and abdominal wounds), Ineffective airway clearance, r/t artificial airway and Risk for unstable blood glucose. Alteration in air exchange (tracheotomy and mechanical ventilator at bedtime) was listed as an active care plan problem four out the seven days reviewed (10/7, 10/6, 10/4 & 10/3/17). There was no documentation for ineffective airway clearance as an active care plan problem on 10/9, 10/8 & 10/5/17 and patient was documented to continue to need mechanical ventilation and had tracheotomy present. Potential for infection (wounds present, urinary tract infection) was listed as an active care plan problem on four out of seven days reviewed (10/7, 10/6, 10/4 & 10/3/17). There was no documentation for potential for infection as an active care plan problem on 10/9, 10/8, 10/5 & 10/2/17 and there was no documentation that wound care needs or antibiotic therapy had changed or stopped. Potential for physical injury/fall risk r/t weakness was listed as an active care plan problem on one out of seven days reviewed (10/8/17). There was no documentation indicating that potential for physical injury/fall risk was an active care plan problem not that Patient #1's physical weakness condition improved. Impaired mobility bed/physical/wheelchair was an active care plan problem on one of seven days reviewed (10/8/17). There was no documentation that impaired mobility was an active care plan problem on 10/9, 10/7, 10/6, 10/5, 10/4 & 10/3/17 no documentation indicating that mobility improved and was no longer a problem. Self-care deficits-bathing/hygiene, feeding/toileting/weakness/pain/anxiety was listed as an active care plan problem on four out of seven days reviewed (10/9, 10/7, 10/6, and 10/5/17). Self-care deficit is not documented as an active care plan problem on 10/8, 10/4, 10/3 and 10/2/17 and no documentation of patient condition change indicating that Patient #3's self care requirements improved to being independent.

Patient #2's medical record was reviewed on 11/14/17 at 1:40 PM. Patient #2's "Admission History & Physical" revealed patient was admitted on 10/9/17 with admitting diagnosis of Multiple myeloma (cancer), severe protein malnutrition, acute kidney injury, T12 compression fracture, respiratory failure, pulmonary edema, MRSA (methicillian resistant staph aureus) bacteremia, pneumonia and enteral tube feedings (thru a tube directly into stomach).

Review of Patient #2's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" and supplemental "PLAN OF CARE" dates 10/28-10/18/17 active care plan problems included the following: Alteration in comfort (pain) dates 10/28-10/18/17, alteration in air exchange and potential for harm/injury related to removal of medical devices, Potential for physical injury/fall risk related to unsteady gait, weakness, alteration in skin integrity, alteration in nutrition (receiving enteral tube feedings) and impaired mobility (related to weakness). Potential for infection (septic with community acquired Methicillin resistant staph aureus pneumoconiosis pneumonia and antibiotic therapy) was listed as an active problem on three out of seven days reviewed (10/25, 10/23-10/20/17). There was no documentation of potential for infection as an active care plan problem on 10/28, 10/27 & 10/26/17 and no documentation of discontinuation of antibiotic therapy. Self-care deficits (requires set up assist with all activities of daily living) was an active care plan problem on one out of seven days reviewed (10/18/17). There was no documentation that self care deficits was an active care plan problem 10/28-10/19/17 and patient documented as requiring assist with activities of daily living.

Patient #3's medical record was reviewed on 11/14/17 at 1:55 PM. Patient #3's "Admission History & Physical" revealed patient was admitted on 7/28/17 with admitting diagnosis of ischemic bowel surgery 7/8/17 requiring an abdominal wound, below the knee amputation, colostomy (stoma to drain stool from colon), NPO (nothing by mouth) receiving enteral tube feedings and total parental nutrition, diabetes mellitus requiring blood sugar checks and insulin (medication given to lower blood glucose) administration, and pneumonia.

Review of Patient #3's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" and supplemental "PLAN OF CARE" dates 10/17-10/11/17 active care plan problems included the following: Alteration in comfort (pain), potential for infection (abdominal wound, pneumonia and antibiotic therapy), alteration in sleep, potential for physical injury related to fall risk, renal insufficiency, and alteration in skin integrity (abdominal wound). There was no documented active care plan problem for alteration in nutrition (patient receiving nothing by mouth (NPO) and on total parental (intravenous) nutrition for any of the seven days reviewed. There was no documented active care plan problem for alteration in elimination (patient has colostomy to drain stool from bowel) for any of the seven days reviewed. Colostomy documented for all seven days reviewed. Risk for unstable blood sugars (related to has diagnosis of diabetes mellitus receiving insulin) was documented as an active care plan problem on three out of seven days reviewed (10/13, 10/12 & 10/11/17). There was no documentation of risk for unstable blood glucose as an active care plan problem on 10/17, 10/16, 10/15 & 10/14/17 and no documentation indicating patient was no longer receiving insulin or blood glucose monitoring. Self-care deficit (patient is documented as being partial/moderate assist for all cares and repositioning was an active care plan problem on three out of seven days reviewed (10/15, 10/13 & 10/11/17). There was no documentation of self-care deficit as an active care plan problem on 10/17, 10/16, 10/14 and 10/12/17 and no documentation of patient condition change indicating that Patient #3's self care requirements improved to being independent.

Patient #4's medical record was reviewed on 11/14/17 at 2:20 PM. "Admission History & Physical" revealed patient was admitted on 10/20/17 with admitting diagnosis of Pulmonary Hypertension, hypoventilation syndrome on chronic oxygen, Congestive Heart Failure, pneumonia and contact precautions for Methicillin Resistant Staph Aureus.

Review of Patient #4's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" and supplemental "PLAN OF CARE" dates 11/3-10/27/17 active care plan problems included the following: Alteration in comfort (pain), Alteration in air exchange (required 6-10 liters of oxygen on admit), Potential for infection (antibiotic therapy for pneumonia on admission) and Alteration in elimination (related to indwelling Foley catheter to drain bladder and incontinence after Foley was removed) and Impaired mobility. Alteration in skin integrity (related to wounds on right lower extremity, decreased mobility and incontinence) was initiated as an active care plan problem on six out of eight days reviewed (11/3, 11/2, 10/30, 10/29, 10/28 & 10/27/17). There was no documentation of alteration in skin integrity as an active care plan problem on 11/1 & 10/31/17 and no documentation of patient wound needs or condition change indicating no longer receiving wound treatment. Self-care deficit was listed as an active problem (patient required partial/supervisional assistance with cares) on four out of eight days reviewed (10/30, 10/29, 10/28 & 10/27/17). There was no documented active self-care deficit care plan problem on 10/31, 11/1, 11/2 & 11/3/17 and no documentation indicating that the patient's self care requirements improved to being independent.

Patient #5's medical record was reviewed on 11/14/17 at 2:40 PM. "Admission History & Physical" revealed patient was admitted on 9/8/17 with admitting diagnosis of asthma, diabetes mellitus requiring blood glucose checks and insulin (medication given to lower blood glucose) administration, hypertension, coronary artery disease, peripheral vascular disease (decreased blood flow in lower extremities), ischial (lower back and hip) and sacral (base of the spine)wound, Clostridium Difficile (infectious diarrhea) colitis, Vancomycin resistant enterococcus infection in wound, ileus with ostomy (stoma to outside of body from colon to divert stool) diverting related to sacral wound, enteral tube (directly into the stomach)feedings patient to have nothing by mouth, sepsis (infection throughout body), dysphagia (difficulty swallowing) and an indwelling Foley catheter related to neurogenic bladder and wounds.

Review of Patient #5's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" and supplemental "PLAN OF CARE" dates 9/20-9/26/17 active care plan problems included the following: Anxiety, Alteration in mental status, Alteration in comfort, Alteration in air exchange, Potential for harm/injury related to removal of medical devices, Alteration in sensory perception and Renal Insufficiency. Potential for infection was listed as an active care plan problem four out of the seven days reviewed (9/26, 9/22, 9/21 & 9/20/17) with no documented improvement in wound status indicating it was no longer a problem on the other three days (9/25, 9/24 & 9/23/17). Alteration in elimination (related to indwelling Foley catheter into bladder) was listed as an active care plan problem four out of the seven days reviewed (9/24, 9/23, 9/22 & 9/21/17). There was no documentation for an alteration in elimination active care plan problem on 9/25, 9/24 & 9/20/17 and patient was documented to have indwelling Foley catheter on those days. Alteration in skin integrity (stage 5 out of 5 wounds on sacrum and ischium) was listed as an active care plan problem four out of seven days reviewed (9/26, 9/22, 9/21 & 9/20/17). There was no documentation for an alteration in skin integrity active care plan problem on 9/25, 9/24 & 9/23/17 and no documentation of patient wound needs or condition change indicating no longer receiving wound treatment. Alteration in nutrition (related to enteral tube feedings and patient being nothing by mouth) was listed as an active care plan problem three out of the seven days reviewed (9/25, 9/22 & 9/21/17). There was no documentation for an alteration in nutrition active care plan problem on 9/26, 9/24, 9/23 & 9/20/17 and the patient was documented to have been receiving enteral tube feedings and to receive nothing by mouth. Risk for unstable blood sugars (related to diagnosis of diabetes mellitus, insulin administration and wound healing) was listed as an active care plan problem two out of the seven days reviewed (9/24 & 9/23/17). There was no documentation for a risk for unstable blood sugars active care plan problem on 9/26, 9/25, 9/22, 9/21 & 9/20/17 and patient was still receiving blood glucose monitoring, insulin (medication given to lower blood glucose) administration and wound care. Self-care deficits (Patient #5 dependent on staff for all cares and repositioning) was listed as an active care plan problem three out of the seven days reviewed (9/26, 9/24 & 9/23/17). There was no documentation for self-care deficits as an active care plan problem 9/25, 9/22, 9/21 & 9/20/17 and patient is documented to be dependent on staff for all cares and repositioning.

Patient #7's medical record was reviewed on 11/14/17 at 3:35 PM. "Admission History & Physical" revealed patient was admitted on 10/16/17 with admitting diagnosis of mechanical ventilation following acute hypoxic respiratory failure and tracheotomy present, chest tube placed on left side (tube into pleural space to drain fluid and keep lung inflated), candida and escherichia coli infection in pleural fluid, fevers, hypertension, dysphagia (difficulty swallowing) requiring enteral tube feedings (directly into the stomach) and receiving nothing by mouth, small bowel perforation 9/5/17 requiring surgery and surgical incisional wound requiring wound vac, protein malnutrition, deep vein thrombosis (blood clot) of right upper extremity, anemia, anxiety and depression, encephalopathy (swelling of the brain), indwelling Foley catheter (drains urine from the bladder) and debilitation.

Review of Patient #7's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" and supplemental "PLAN OF CARE" dates 9/20-9/26/17 active care plan problems included the following: Anxiety, Alteration in comfort (pain), Alteration in air exchange (related to mechanical ventilation), Potential for harm/injury related to removal of medical devices, Potential for infection and Impaired mobility. Alteration in elimination related to indwelling Foley catheter was listed as an active care plan problem four out the seven days reviewed (11/12, 11/11, 11/8 & 11/5/17). There was no documentation for alteration in elimination as an active care plan problem on 11/10, 11/9, 11/7 & 11/6/17 and patient was documented to have indwelling Foley catheter on those days. Alteration in skin integrity related to abdominal wound post surgery was listed as an active care plan problem four out of the seven days reviewed (11/8, 11/7, 11/6 & 11/5/17). There was no active alteration in skin integrity on 11/12, 11/11 & 11/10/17 and no documentation of patient wound needs or condition change indicating no longer receiving wound treatment. Alteration in nutrition related to difficulty swallowing, enteral tube feedings and receiving nothing by mouth was listed as an active care plan problem five out of the seven days reviewed (11/12, 11/11, 11/8, 11/7 & 11/6/17). There was no documentation for alteration in nutrition as an active care plan problem on 11/10, 11/9 & 11/5/17 and the patient was documented to have been receiving enteral tube feedings and to receive nothing by mouth. Ineffective airway clearance related to tracheotomy present was listed as an active care plan problem three out of the seven days reviewed (11/8, 11/7 & 11/6/17). There was no documentation for ineffective airway clearance as an active care plan problem on 11/12, 11/11, 11/10 & 11/5/17 and patient was documented to continue to need mechanical ventilation and had tracheotomy present. Self-care deficit related to being totally dependent on staff for all cares and repositioning was listed as an active care plan problem three out of the seven days reviewed (11/8, 11/7 & 11/6/17). There was no documentation for self care deficits as an active care plan problem 11/12, 11/11, 11/10 & 11/5/17 and the patient was documented to be dependent on staff for all cares and repositioning.

Patient #8's medical record was reviewed on 11/14/17 at 3:55 PM. "Admission History & Physical" revealed patient was admitted on 10/27/17 with admitting diagnosis' of right shoulder streptococcus septic arthritis requiring antibiotic therapy, coccidioidomycosis (fungal infection), group B streptococcus bacteremia, Clostridium Difficile (infectious diarrhea) requiring antibiotic therapy and contact precautions, urinary tract infection, haemophilus healthcare acquired pneumonia, diabetes mellitus requiring blood glucose monitoring and insulin administration, hypertension (elevated blood pressure), heart failure, acute hypoxic respiratory failure requiring oxygen therapy, debility complicated by right shoulder septic arthritis and prolonged hospitalization requiring hoyer (mechanical lift) for transfers, and pain.

Review of Patient #8's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" and supplemental "PLAN OF CARE" dates 11/12-11/6/17 active care plan problems included the following: Alteration in comfort (pain), Alteration in sensory perception, Alteration in tissue perfusion, Alteration in elimination, Alteration in sleep, Fluid volume excess and Potential for skin integrity impairment. Alteration in air exchange related to oxygen therapy was listed as an active care plan problem five days out of seven reviewed (11/12, 11/11, 11/8, 11/7 & 11/6). There was no documentation for alteration in air exchange as an active care plan problem on 11/10 & 11/9/17 and patient was documented as requiring continued oxygen therapy. Potential for infection related to active infectious process (osteomyelitis, fungal infection, strep infection and infectious diarrhea) was listed as an active care plan problem three days out of seven reviewed (11/8, 11/7 & 11/6/17). There was no documentation for potential for infection as an active care plan problem on 11/12, 11/11, 11/10 & 11/9/17 and patient was documented as still receiving antibiotic therapy. Potential for physical injury/fall risk related to weakness and requiring hoyer lift for transfers was listed as an active care plan problem three out of the seven days reviewed (11/12, 11/11 & 11/8/17). There was no documented active care plan problem for potential for physical injury/fall risk on 11/10, 11/9, 11/7 & 11/6/17 and documentation stated no indication of patient's increased independence or improved condition with transfers and cares. Risk for unstable blood sugars (related to diagnosis of diabetes mellitus, insulin administration and blood glucose monitoring) was listed as an active care plan problem five out of the seven days reviewed (11/10, 11/9, 11/8, 11/5 & 11/6/17). There was no documentation for a risk for unstable blood sugars active care plan problem on 11/12, 11/11 & 11/5/17 and patient was documented as still receiving blood glucose monitoring and insulin (medication to lower blood glucose) administration. Self-care deficit related to being totally dependent on staff for all cares and repositioning was listed as an active care plan problem two out of the seven days reviewed (11/7 & 11/6/17). There was no documentation for self-care deficits as an active care plan problem 11/12, 11/11, 11/10, 11/9 & 11/5/17 and the patient was documented to require setup, supervision or partial/moderate assistance by staff for all cares and repositioning.

Patient #9's medical record was reviewed on 11/14/17 at 4:00 PM. "Admission History & Physical" revealed patient was admitted on 11/1/17 with admitting diagnosis' of respiratory failure requiring tracheotomy and mechanical ventilation, chronic obstructive pulmonary disease, pneumonia requiring antibiotic therapy, noonan (genetic disorder) syndrome, anxiety, enteral (directly into stomach) tube feedings, steroid induced hyperglycemia requiring blood glucose monitoring and insulin (medication to lower blood glucose)administration as needed according to glucose results, increased anxiety and shortness of breath and debilitation totally dependent on staff for cares and hoyer (mechanical lift) for all transfers.

Review of Patient #9's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" and supplemental "PLAN OF CARE" dates 11/12-11/7/17 active care plan problems included the following: Anxiety, Alteration in comfort (pain), Alteration in air exchange, Potential for infection, Alteration in tissue perfusion and Alteration in skin integrity. Alteration in nutrition related to enteral tube feedings was listed as an active care plan problem three out of six days reviewed (11/12, 11/11 & 11/10/17). There was no documented active care plan problem for alteration in nutrition on 11/9, 11/8 & 11/7/17 and patient was documented to be receiving nothing by mouth and enteral tube feedings. Impaired mobility bed/physical/wheelchair related to patient being totally dependent on staff for all cares and turning and repositioning was documented as an active care plan problem on three out of six days reviewed (11/12, 11/11 & 11/10/17). There was no documentation of impaired mobility being an active care problem on 11/9, 11/8 & 11/7/17 and patient was documented to require total assistance from staff for all cares and turning and repositioning. Ineffective airway clearance related to artificial airway (tracheotomy) was documented as an active care plan problem on three out of six days reviewed (11/12, 11/11 & 11/10/17). There was no documentation for ineffective airway clearance on 11/9, 11/8 & 11/7/17 and patient was documented to have tracheotomy present and mechanical ventilation assistance.

Patient #10's medical record was reviewed on 11/14/17 at 4:17 PM. "Admission History & Physical" revealed patient was admitted on 11/11/17 with admitting diagnosis' of diabetic foot ulcer with surgical toe amputation and was non weight bearing, diabetes mellitus requiring blood glucose monitoring and insulin (medication to lower blood glucose) administration, non-alcoholic induced enlarged liver, diabetic neuropathy, restless leg syndrome, debility (non-weight bearing) and increased anxiety.

Review of Patient #10's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" and supplemental "PLAN OF CARE" dates 11/12-11/11/17 active care plan problems included the following: Anxiety, Alteration in comfort, Potential for infection (related to surgical incision on foot), Alteration in skin integrity (related to surgical incision on foot) and Impaired mobility related to being non weight bearing. There was no documentation of risk for unstable blood glucose being an active care plan problem for either day and the patient was having blood glucose monitoring and insulin administration.

Based on record review and interview the facility failed to ensure the quality of medical care (oral cares, repositioning and mobility needs)provided to patients. In 8 out of 10 records reviewed (Patients #1, 2, 3, 4, 5, 7, 8 & 9).

Findings include:

Patient #1's medical record was reviewed on 11/14/17 at 10:40 AM. Patient #1 was admitted on 8/25/17 with admitting diagnosis of Chronic Obstructive Pulmonary Disease with respiratory failure requiring a tracheotomy (stoma into trachea to assist with breathing) and mechanical ventilation assistance (admitted on ventilator weaned to just requiring assistance at bedtime while in hospital), Abdominal Aorta Aneurysm repair with an endovascular leak and graft placement 6/17, right groin incisional wound with flap requiring a wound vac, asystole (heart stopped) requiring pacemaker placement 7/17, left sided pleural effusion (collection of fluid on lung) requiring thoracentesis twice (aspiration of fluid with a needle into chest) and chest tube placement (tube placed into chest to provide constant suction to keep lung inflated and drain fluid) 9/19/17-10/6/17, right lung pneumothorax requiring chest tube 8/11/17-8/16/17, sacral decubitus ulcer, fevers, dysphagia (difficulty swallowing) requiring enteral feedings (tube feedings directly into stomach), urinary tract infection, fevers, and debilitation. On admission Patient #1 was only able to sit on the side of bed and was very unsteady.

Per interview with Interim Chief Nursing Officer B on 11/14/17 at 11:15 AM oral cares are "expected to be done twice a day. If the patient is receiving RT (respiratory therapy) care related to a trach (tracheotomy) or intubated oral cares are provided by respiratory therapy. If the patient is not receiving respiratory therapy the CNA (certified nursing assistant) should be doing two times a day." In regards to repositioning Interim Chief Nursing Officer B stated "repositioning is done every 2 hours, on the odd hour, by the CNA's."

The facility policy titled "Clinical Services" #S05-G dated 10/1/17 was reviewed on 11/14/17 at 11:15 AM. This document states on page 2 under "Hygiene" "Oral Care-Every AM before breakfast, every HS. Oral care for NPO (nothing by mouth), tube feeding-Every 4 hours". Continuing on page 2 under "Activity/Mobility" "Bedfast patients turned-Every 2 hours" and in regards to mobility "Within 8 hours of admission and weekly. Nursing is responsible for determining mobility level". On page 4 under "Respiratory" document states "Oral care for vent patients-Every 4 hours and PRN (as needed). Oral Care for non-vent patients-BID (twice a day) and PRN".

Upon review of Patient #1's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" and Respiratory Therapy "MECHANICAL VENTILATOR/ATC FLOW SHEET" dates 10/10/17-10/3/17. On 10/10, 10/9, & 10/4/17 Patient #1 did not receive HS (bedtime) oral cares, and on 10/8/17 there are no documented oral cares for 24 hours. On page 8 of the "24 HOUR PATIENT RECORD & PLAN OF CARE" Patient #1 has no documented turning and reposition on 10/4/17 from 1:00 PM to 7:00 PM and on 10/2/17 from 7:00 AM to 8:00 PM. Under "Mobility" on page 8 on 10/8/17 Patient #1 is documented to have received ROM (range of motion) one time (ordered QID-four times a day) and was not OOB (out of bed) for 24 hours (ordered BID-twice a day), 10/7 & 10/6/17 ROM completed twice (ordered four times a day) and OOB one time (ordered twice a day), 10/4/17 no ROM documented (ordered four times a day) and OOB one time (ordered twice a day), and on 10/3/17 there is no documented OOB (ordered twice a day).

Patient #2's medical record was reviewed on 11/14/17 at 1:40 PM. Patient #2 was admitted on 10/9/17 with admitting diagnosis of Multiple myeloma (cancer), severe protein malnutrition, acute kidney injury, T12 compression fracture, respiratory failure, pulmonary edema, MRSA (Methicillin Resistant Staph Aureus) bacteremia, pneumonia and enteral tube feedings (thru a tube directly into stomach).

Review of Patient #2's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" dates 10/28-10/18/17 revealed no oral cares documented on 10/28, 10/25 & 10/18/17. On 10/24, 10/23, 10/22 & 10/21/17 oral cares were documented once per 24 hour period. There is no documented turning and repositioning on 10/26/17 from 7:00 AM to 8:00 PM and on 10/24/17 from 7:00 PM to 6:00 AM. On page 8 under "Mobility" on 10/25, 10/24, 10/20 & 10/18/17 there is no documented charting. On 10/23/17 ROM (range of motion) is documented twice (ordered four times a day), 10/22 & 10/21/17 ROM documented once (ordered four times a day).

Patient #3's medical record was reviewed on 11/14/17 at 1:55 PM. Patient #3 was admitted on 7/28/17 with admitting diagnosis of ischemic bowel surgery 7/8/17 requiring an abdominal wound, below the knee amputation, colostomy (stoma to drain stool from colon), NPO (nothing by mouth) receiving enteral tube feedings, diabetes mellitus requiring blood sugar checks and insulin administration, and pneumonia.

Review of Patient #3's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" dates 9/14-9/6/17 revealed no oral cares documented on 9/12, 9/11, & 9/10/17. Oral cares documented once a day (ordered every four hours as patient is NPO) on 9/8 & 9/6/17. There is no documented turning and repositioning 9/13, 9/11 & 9/8/17 for 24 hour period and on 9/14 & 9/6/17 none documented from 8:00 PM to 6:00 AM. On 9/14, 9/10 & 9/8/17 there is no documentation under "Mobility" for the 24 hour period, 9/10, 9/9, 9/8 & 9/6/17 there is no documented ROM (range of motion ordered four times a day), on 9/13/17 one documented ROM (ordered four times a day), 9/12 & 9/7 Patient #3 is not documented OOB (out of bed) as ordered twice a day and 9/9, 9/8 & 9/6/17 is documented OOB once each day (ordered twice a day).

Patient #4's medical record was reviewed on 11/14/17 at 2:20 PM. Patient #4 was admitted on 10/20/17 with admitting diagnosis of Pulmonary Hypertension, hypoventilation syndrome on chronic oxygen, Congestive Heart Failure, pneumonia and contact precautions for Methicillin Resistant Staph Aureus.

Review of Patient #4's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" dates 11/3-10/27/17 revealed no oral cares documented on 11/3 & 11/2/17 and oral cares documented once (ordered twice a day) on 11/1, 10/30 and 10/27/17. There was no documented turning and repositioning on 11/3/17, on 11/2/17 none documented 7:00 PM thru 6:00 AM, 11/1/17 none documented 11:00 AM thru 7:00 PM, and 10/31, 10/29 & 10/27/17 none documented 7:00 AM thru 8:00 PM. On 11/3, 10/29 & 10/28/17 on page 8 under "Mobility" there was no documentation for a 24 hour period. On 11/1/17 ROM documented three times (ordered four times a day), 10/31 & 10/27/17 ROM documented once (ordered four times a day) and on 10/30/17 ROM documented twice (ordered four times a day). Patient #4 was not documented OOB (out of bed) on 10/30 & 10/28/17 (ordered twice a day) and OOB once on 10/27/17 (ordered twice a day).

Patient #5's medical record was reviewed on 11/14/17 at 2:40 PM. Patient #5 was admitted on 9/8/17 with admitting diagnosis' of asthma, Diabetes Mellitus requiring blood glucose checks and insulin administration, hypertension, coronary artery disease, sacral and ischial decubitus ulcers with vancomycin resistant enterococcus infection, bowel resection, enteral tube feedings, total parental nutrition (all nutritional needs received via intravenous solution), dysphagia ( difficulty swallowing) and neurogenic bladder requiring indwelling Foley catheter (drains bladder of urine).

Review of Patient #5's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" dates 9/26-9/20/17 revealed no oral cares on 9/25/17 for 24 hour period (ordered every 4 hours as patient was NPO-nothing by mouth) and on 9/26 & 9/20/17 documented oral cares once in 24 hour period. There was no documented turning and repositioning (ordered every two hours) on 9/26/17 from 7:00 AM thru 3:00 PM, on 9/25/17 from 7:00 AM thru 8:00 PM, on 9/24/17 from 7:00 PM thru 12:00 AM, 9/23/17 from 9:00 AM thru 2:00 PM and 3:00 PM thru 10:00 PM, 9/22/17 7:00 AM thru 8:00 PM, and 9/21/17 10:00 AM thru 10:00 PM. On 9/26, 9/25 & 9/23/17 on page 8 under "Mobility" there was no documentation of ROM (range of motion) being done for 24 hour period (ordered four times a day) and on 9/21 & 9/22/17 ROM was documented two times (ordered four times) and on 9/20/17 ROM was documented three times (ordered four times). Patient #5 was not documented OOB (out of bed) on 9/25 & 9/20/17 (ordered twice a day) and was documented out of bed once on 9/22 & 9/23/17 (ordered twice a day).

Patient #7's medical record was reviewed on 11/14/17 at 3:35 PM. Patient #7 was admitted on 10/16/17 with admitting diagnosis' of tracheotomy and requiring mechanical ventilation, pleural effusion (consolidation of fluid in lung) requiring chest tube placement to provide drainage and pressure to keep lung inflated, positive blood cultures and antibiotic therapy, hypertension, dysphagia (difficulty swallowing) requiring enteral tube feedings and nothing by mouth, small bowel perforation with surgical intervention and resulting wound requiring wound vac, deep vein thrombosis 9/18/17, history of gastro intestinal bleeding, encephalopathy (swelling of the brain) and significant anxiety.

Review of Patient #7's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" dates 11/12-11/2/17 revealed no oral cares documented 11/12 & 11/5/17, once a day oral cares documented (ordered every four hours as patient is NPO) on 11/11, 11/10 (documented by nursing staff), 11/9, 11/4 & 11/2/17 (by respiratory therapy), and two times a day on 11/8, 11/7, 11/6, 11/5, and 11/3/17 documented by respiratory therapy. There was no documented turning and repositioning on 11/12/17 from 6:00 PM thru 6:00 AM (ordered every two hours). On 11/5/17 there was no documented ROM (range of motion) ordered four times a day under "Mobility" on page 8 of nursing 24 hour flow sheet, on 11/11 & 11/6/17 there was three documented ROM (ordered four times a day) and on 11/7/17 there was one documented ROM (ordered four times a day).

Patient #8's medical record was reviewed on 11/14/17 at 3:55 PM. Patient #8 was admitted on 10/27/17 with admitting diagnosis' of chronic kidney disease, chronic obstructive pulmonary disease, asthma, diabetes mellitus requiring blood glucose checks and insulin administration, positive blood cultures with antibiotic therapy, osteomyelitis, Clostridium Difficile Bacteria (infectious diarrhea) colitis, urinary tract infection, and debilitation requires hoyer (mechanical lift) in and out of bed.

Review of Patient #8's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" dates 11/12-11/6/17 revealed oral cares provided once (ordered twice a day) on 11/10, 11/7 & 11/6/17. There was no documented turning and repositioning on 11/7/17 from 8:00 PM thru 6:00 AM and on 11/6/17 from 11:00 AM thru 10:00 PM (ordered every 2 hours). On 11/12 & 11/6/17 there was no documented ROM (range of motion) was ordered four times a day, 11/11/17 ROM was documented twice a day (ordered four times a day) and on 11/8/17 ROM was documented once a day (ordered four times a day).

Patient #9's medical record was reviewed on 11/14/17 at 4:00 PM. Patient #9 was admitted on 11/1/17 with admitting diagnosis' of respiratory failure requiring a tracheotomy and mechanical ventilation, chronic obstructive pulmonary disease, diabetes mellitus requiring blood glucose checks and insulin administration, pneumonia, noonan syndrome (genetic disorder), anxiety, enteral tube feedings and was totally dependent on staff for all cares and required a hoyer (mechanical life) for all transfers.

Review of Patient #9's "24 HOUR AND PATIENT RECORD & PLAN OF CARE" dates 11/12-11/1/17 revealed no oral cares documented on 11/6, 11/4 & 11/2/17 by either nursing nor respiratory staff (ordered every four hours as patient was NPO). On 11/11, 11/9, 11/8, 11/3 & 11/1/17 oral cares documented once in 24 hour period (ordered twice a day). There was no documented turning and repositioning on 11/10/17 from 12:00 PM thru 7:00 PM, on 11/9/17 from 11:00 AM thru 6:00 PM and on 11/8/17 from 7:00 AM thru 9:00 PM. On page 8 of 24 hour flow sheet under "Mobility" there was no documentation of any ROM (range of motion) on 11/8 & 11/7/17, there was one documented ROM (ordered four times a day) on 11/9/17 and three documented ROM on 11/11 & 11/10/17. There was no documentation on 11/11, & 11/8/17 of Patient #9 getting OOB (out of bed) as was ordered twice a day and on 11/9 & 11/7/17 there was one documented episode of patient getting OOB (ordered twice a day)