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Based on interview, record review and policy review, the facility failed to develop comprehensive nursing care plans that addressed all patient needs that included measurable goals, individualized interventions and timetables based upon the history and assessment for three (#6, #10 and #13) of six current patients whose records were reviewed. This failure had the potential to deny all patients admitted to the facility care based upon their individual needs. The facility census was 25.

Findings included:

1. Record review of the facility's policy titled, "Assessment," revised 05/2013, showed the following directives for staff:
- An RN (registered nurse) will evaluate the care for each patient upon admission and when appropriate on an ongoing basis in accordance with accepted standards of practice, occurring routinely each shift and more frequently as indicated.
- The plan of care will be evaluated and updated with changes in condition and when problems resolve by the nursing staff.
- The Plan of Care will be developed by the RN to reflect the RN review/revision of the plan of care.
- The RN will document the patient's problems on the plan of care and update this problem list as the patient's condition changes or daily.

2. Record review of Patient #6's History and Physical (H&P) showed he was admitted to the facility on 05/11/15 with complaints of respiratory failure.

Observations throughout the survey from 06/01/15 to 06/04/15 showed the patient had a Foley catheter (tube placed into the bladder used to drain urine) in place.

Record review of the patient's Clinical Plan of Care dated 05/11/15 showed staff did not address or include in his plan of care the use of the Foley catheter.

3. Record review of Patient #13's H&P showed he was admitted to the facility on 06/02/15 with complaints of respiratory failure, renal failure and swallowing difficulty.

Observation on 06/03/15 at 9:20 AM showed the patient rested in bed with soft wrist restraints on both wrists.

Record review of the patient's Clinical Plan of Care dated 06/02/15 showed staff did not address or include in his plan of care the use of restraints.

During an interview on 06/03/15 at 11:15 AM, Staff HH, RN, stated that:
- She was taking care of the patient today and that she received report he was put into restraints because he was pulling at lines.
- The patient did not have an active plan of care related to restraints.
- The expectation was that if staff placed a patient into restraints, the restraint plan of care needed to be initiated.

During an interview on 06/03/15 at 3:05 PM, Staff II, RN, stated that if a patient was placed in restraints, staff should initiate the restraint plan of care.

During an interview on 06/03/15 at 3:50 PM, Staff EE, RN, Case Manager, stated that she expected staff to initiate a plan of care for restraints when they are applied on patients.

During an interview on 06/04/15 at 9:30 AM, Staff O, RN, stated that when staff placed a patient in restraints a plan of care needed to be initiated.

4. Record review of Patient #10's H&P showed:
- He was admitted on 05/19/15.
-The patient was disoriented and his mental status was slowly declining.
- He had a diagnosis of end-stage renal disease (when the kidneys stop working) on hemodialysis (a procedure to remove fluid and waste products from the blood) for 14 years and a plan to continue dialysis.
- He had a diagnosis of protein malnutrition.
- Pain control was planned.

Record review of the patient's medical record showed:
- His care plan for bowel and bladder was initiated on 06/01/15.
- On 05/19/15 the nurse's notes had documentation that he was annuric (no or little passage of urine) at times.
- Staff started the cognition (mental status) care plan on 05/26/15.
- Staff failed to initiate a plan of care related to dialysis (physician's orders showed continued dialysis while hospitalized).
-The pharmacy automated medication dispensing system report showed medication for pain was removed for the patient each day he was hospitalized.
- Staff failed to initiate a plan of care for pain on 06/01/15.
-The dietician completed the nutritional assessment on 05/22/15, but failed to initiate the nutrition plan of care until 05/25/15.

During interviews on 06/02/15 at 3:20 PM, and 06/03/15 at 2:15 PM, Staff N, Licensed Practical Nurse (LPN), stated that Patient #10 should have had a plan of care for fluid and electrolytes since he had dialysis and he should have had a plan of care for pain prior to 06/01/15 since he received pain medication.

During an interview on 06/03/15 at 2:45 PM, Staff DD, Registered Dietician, stated that typically she started the nutritional plan of care the day she completed the nutritional assessment. Staff DD stated that she did not know why she failed to complete this plan of care timelier, but it was her responsibility.

During an interview on 06/04/15 at 3:45 PM, Staff A, RN, Director Of Nursing, stated that she expected staff to follow the facility's policy and procedures.




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Based on observation, interview, record review and policy review the facility failed to ensure physician's orders were followed for medication administration through a Percutaneous Endoscopic Gastrostomy (PEG, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach for nutrition, fluids and/or medications) for two (#1 and #2) of two patients. This failure increased the risk for patient aspiration, for all patients who received medication by mouth (PO) rather than as ordered by PEG tube. The facility census was 25.

Findings included:

1. Record review of the facility's policy titled, "Drug Administration General," dated 01/2012, showed direction for staff to:
-Be attentive to cautionary statements on the Medication Administration Record (MAR) such as "shake well," "do not crush," and "per Nasogastric tube (NG) tube.
-Verify drugs to be administered with the physician's order;
-Review the right route for the medication; and
-Consult with a pharmacist or prescriber if any concerns or questions about any aspect of the drug administered.

2. Observation on 06/02/15 at 9:00 AM showed Staff J, Registered Nurse (RN), administered ten medications PO to Patient #1.

Record review of the patient's History and Physical (H&P), dated 05/13/15, showed a PEG tube was inserted at a previous facility. The patient currently had a diagnosis of protein malnutrition.

Record review of the patient's physician's orders showed four of the medications were ordered to be given per PEG tube and one was ordered to be given per feeding tube (typically, the word is interchanged for PEG).

During an interview on 06/02/15 at 3:50 PM, Staff J stated that typically as the patient advanced with an ability to swallow and eat, the route of the medication would advance, but the orders are not changed to reflect the change from PEG to PO.

3. Observation on 06/02/15 at 9:00 AM showed Staff O, RN, entered Patient #2's room to administer medications. Staff O handed the patient four medications and the patient took all four by mouth.

Record review of the patient's H&P dated 05/27/15 showed she was admitted to the facility on 05/26/15 with complaints of acute tracheostomy (a surgical procedure to create an opening through the neck into the trachea (windpipe) to provide an airway and to remove secretions from the lungs) ventilator failure (inability to breathe without mechanical assistance) and recent PEG tube placement.

Record review of the patient's Medication Reorder signed and dated on 05/26/15 by the physician showed direction for the four medications to be administered per the PEG tube/feeding tube.

During an interview on 06/02/15 at 4:10 PM, Staff O, RN, stated that:
- She should have administered the patient's medications per the PEG tube or she should have clarified with the physician if the patient could take medications by mouth.
- The patient did not have a physician's order to administer medications by mouth.
- She should have administered the patient's medications per the PEG tube until the physician changed the order for the patient to take medications by mouth.

During an interview on 06/04/15 at 8:50 AM, Staff Z, Pharmacist, stated that:
- He expected staff to follow physician's orders when administering medications to include the proper route.
- Staff should not change the medication route without a physician's order.
- He expected staff to follow the facility's pharmacy policy and procedures.

During an interview on 06/04/15 at 3:05 PM, Staff A, RN, Director Of Nursing, stated that she expected staff to follow the physician's order for route when administering medications or staff should clarify with the physician if the medication route can be changed from PEG tube/feeding tube to oral. Staff A stated that she expected staff to follow the facility's policy and procedures.






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