Kuakini Medical Center

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 39853 Based on interviews, document and record review, the care provided by nursing services did not meet the standard of care for patients to meet their highest level of well-being. Due to the nature of the deficiencies identified in Nursing Plan of Care and RN supervision of Care, this resulted in a Condition Level deficiency Nursing Services. Findings include: Cross Reference A-0396 Nursing Plan of Care The facility patient care planning process does not meet the standard of practice. The facility interdisciplinary care plans are incomplete, do not include interventions or represent the patients overall condition. As result of this deficiency, the facility individual patient care plans (CP)s are not detailed, well-structured/organized with clear strategies, tasks for the care team to ensure consistent and personalized care for the patients to meet their highest level of health and well being. Without the interventions included in the CP, the communication is disjointed and located in different patient records. Cross Reference A-0395 RN Supervision of Nursing Care The facility failed to provide evidence that a Registered Nurse (RN) supervised the nursing care of three patients (P1, P2, and P3) of a sample size of three. Specifically, the RN did not ensure nursing and provider ordered interventions, as well as the standard of care was provided and treatment implemented on a consistent basis for the wound care of these patients. As a result of this deficiency, P2’s pressure ulcer increased, and P1 and P2 were put at higher risk of bad outcomes.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 39853 Based on observation, interviews, document and record review, the facility failed to provide evidence that a Registered Nurse (RN) supervised the nursing care of three patients (P1, P2, and P3) of a sample size of three. Specifically, the RN did not ensure nursing and provider ordered interventions, as well as the standard of care was implemented on a consistent basis for the wound care of these patients. As a result of this deficiency, P2’s pressure ulcer increased, and P1 and P2 were put at higher risk of bad outcomes. Findings include: 1) P1 was a 79 year old male who was admitted to the hospital on 06/01/2024 for cellulitis of the left arm. He was bedbound, due to mobility issues and had a wound on his sacrum prior to admission. He was discharged home on 06/04/2024 at 03:02 PM. RR of P1’s medical records revealed the following: Wound Care Consult 06/02/2024 included: - Coccyx pressure injury stage 2. “ Partial thickness....scant serous drainage. ...Measurement 2.0 cm 0.5 cm 0.1 cm. ...Recommend zinc skin barrier with bordered foam dressing daily/PRN (as needed) for soilage and ...mattress P-500 (helps relieve pressure).” - Bilateral gluteal /sacral MASD (moisture associated skin damage- ... Recommend zinc barrier with bordered foam dressing/PRN per soilage ...” Orders 06/03/2024 09:24 AM included: -“SPD specialty bed” -“Turn and Reposition frequently” -“coccyx/sacral/gluteal, DAILY. Nurse to apply thick layer of Zinc Skin Barrier Paste and cover with bordered foam dressing. Daily/PRN soilage. Frequently weight shift.” Nursing Records: Initial assessment progress note on 06/02/2024 01:00 AM, identified the sacral wound and took a picture per facility policy. The picture of the wound had a tape measure laid next to the wound, but did not record measurements. Flowsheet (documents interventions), with positioning entries in the section “Activities of daily living.” This area of the flowsheet provides drop down menu to choose what position the patient is currently in. Choices include, supine, right or left. P1’s Flowsheet recorded the following entries for positioning: 06/02/2024 10:00 AM: “Repositioned every 2 hours.” 06/02/2024 09:00 PM: “Repositioned every 2 hours” 06/03/2024 01:00 AM, 03:00 AM, 06:00 Am and 08:00 AM: “Repositioned every 2 hours” There were no other entries of repositioning during P1’s hospital stay (discharged 06/04/2024 at 03:32 PM). The flowsheet documented P1 was one and two person assist with bed mobility. Nursing Progress notes with entries related to positioning: 06/02/2024 1:59 AM: “...Action: Paste applied to open wounds on his butt. Positioned on his side and emphasized importance of repositioning every two hours. ...So far cooperative with repositioning.” 06/03/2024 02:52 PM: “...Action: Skin care was done and pt placed in p500 mattress [sic]. Pt turned and repositioned and skin care was done. ...” 06/04/2024 02:55 PM: “...x3 Incontinent of urine. Nurse Aid was able to change diaper but refused bath and pressure injury to be checked.” Family verbalized will change at home and have supplies. There was lack of evidence that the standard of care was provided repositioning P1 during his short hospitalization. 2) P2 is a 97 year old female with a history of Stage 4 Chronic Kidney Disease, hypertension, anemia, and has a pacemaker. She and her family decided against dialysis and were referred for palliative care. P2’s primary language was Ilocano. She required assistance in all ADL’s and has a pressure ulcer due to significant weight loss and poor oral intake. She was admitted to the hospital on 03/08/2024 with shortness of breath and weakness. RR of P2’s medical records revealed the following entries: 03/09/2024 at 01:36 AM, Admission History and Physical (H&P):”... Right buttock stage II pressure ulcers...” 03/14/2024 Provider note: “... Assessment Plan included: Stage 2 coccyx decubitus: An alternating pressure pad is needed due to bilateral upper sacrococcygeal pressure injury. Pt has limited mobility, and is unable to independently make changes in body position so as to significantly alleviate pressure, leading to a stage 2 PU on her sacrum, coccyx and buttock with altered sensory perception, fecal and urinary incontinence and impaired nutrition. A hospital bed is needed ..., and she requires repositioning of her body in a manner not feasible in an ordinary bed, requiring frequent changes in body positioning. Orders: 03/11/2024 Specialty bed. 03/12/2024 Turn and reposition , every two hours. 03/13 /2024 Apply Z guard to pt’s coccyx. At this time please do not apply any foam dressing. Nursing Progress notes: 03/09/24 6:06 AM Admission RN documented: “Skin wise, pt has a stage 2 excoriation to the coccyx.” There was a picture of the wound taken on admission, but measurements were not taken. 03/10/24 10:14 AM: “repositioned q 2 hr., assisted with ADL’s...” 03/10/2024 10:32 PM: “Action: Reposition q2 hr.” 03/11/2024 12:41 PM: “Moans with BLE moves for repositioning. DAR (data, action, response format) charting). ... reposition q 2 hr.” 03/11/24 01:59 PM.: “Focus: “Bilateral upper sacral and coccyx pressure injury (photo taken on admission).” “Data: ...nods during 2-person assistance to reposition on her side. .... Sacral area has 2 pink shallow stage 2 pressure injuries ... ... to upper sacral area. Coccyx has a shallow stage 2 pressure injury measuring approximately 3 x 3 x 0.2 cm. wound edges are poorly defined and surrounding skin is moist and nonblanchable erythema. ... “ “Action: RN2 has assessed skin breakdown, and initiated the topical zinc-oxide based paste to the sacrum, coccyx and buttocks. Discussed this treatment as appropriate since wound beds are shallow, pink and the zinc -oxide paste provides a barrier to moisture. Braden score is 12 and discussed obtaining an order for the P500 specialty bed. RN2 will obtain physicians order for this mattress.” 03/11/2024 02:12 PM: “...She is lying on her right side with pillows and heels elevated with a pillow as well.” 03/12/2024 02:26 PM: “Mediplex drsg applied for prevention. ET (wound) nurse consulted. ...” 03/12/2024 11:45 PM: “...Pt is on P5oo mattress...”03/13/2024 2:12 PM: “Pt turned to the side and foam dressing removed. Pts dressing and soiled diaper with what smells likes urine despite having a Foley in Pts wound is to her coccyx and measures 2.5 x 5 with a red wound bed. Plan was to have a foam dressing on pt to protect the bony area, but after discussing plan with Provider, pt will now have no dressing to area and will apply z guard paste prn. Provider notified that wound is larger than previously assessed and after some thought having a form dressing to the area when the Foley leaks, would cause more damage since the foam dressing would soak up the urine and breakdown the pt’s skin further.” Flowsheet: Entries regarding P2’s wound or positioning after admission assessment on 03/09/2024 at approximately 06:00 AM, included: 03/09/2024 08:00 AM: lying on left side. 03/09/2024 10:00 AM: lying on right 03/09/2924 12:00 PM: wound status “unchanged” 03/09/2024 12:37 PM: wound status “unchanged” 03/09/2024 03:00 PM: wound status “unchanged” 03/09/2024 07:00 PM: documented New Pressure injury finding 2” 03/10/2024 08:49 AM, 10:00 AM, 12:00 AM, 07:00 PM, 09:00 PM, 11:00 PM documented “Reposition every 2 hours” 03/11/2024 02:00 AM, 04:00 AM, 06:00 AM, 08:00 AM, 10:00 AM documented “Reposition every 2 hours” 03/12/2024 06:00 AM, 08:00 AM. 010:00 AM, 12:00 PM, 02:00 PM, 04:00 PM , 06:00 PM , 08:00 PM, 10:00 PM documented “Reposition every 2 hours” There were long periods identified when it was not documented that P2 was repositioned. This included: 03/11/2024 04:00 AM to 04:00 PM, a period of 12 hours. 03/11/2024 10:00 PM to 03/12/1014 10: AM, a period of 12 hours. 03/14/2024 02:00 AM to 07:00 AM.. The documentation by the RN’s of “Reposition every 2 hours” continued through P2’s hospital stay. There were no entries that actually specified if P2 was on her right side, left side, or supine with offloading. Flowsheet coccyx wound measurements: 03/11/2024 12:00 PM: 0.5 x 0.5 depth 0.2 03/12/2024 08:00 PM: 3 x 3 03/13/2024 02:09 PM: 2.5 x 5 There was lack of evidence that the standard of care was provided to P2 during her hospitalization to prevent a preexisting sacral wound from becoming worse. 3) P3 is a 64 year old male with a history of surgery for Left (L) hip fracture with chronic pain. He is on dialysis for end stage renal disease (ESRD). P3 presented to the ED on 05/26/2024 for generalized weakness, diarrhea and shortness of breath (SOB). He was admitted with diagnosis of diarrhea, pneumonia and L hip hardware failure. Record review revealed the following: 05/26/202410:39 PM: Initial nursing assessment of skin integrity documented “Black, Necrotic” tissue to the left middle toe, and “Necrotic” to the right heel. Orders: 05/26/2024 08:09 AM: “Reposition and turn frequently” 05/28/2024 08:11 AM, Treatment Nursing Order: “Lt 2nd toe necrotic, nurse to paint eshcar with Povidone-Iodine swabstick and leave open to air. ...Offload heals when in bed.:” 05/28/2024 08:10 AM, Treatment Nursing Order: “Rt plantar heel, DAILY, nurse to paint eshcar with Povidone-Iodine swabstick and leave open to air. ...Offload heals when in bed.:” Nursing Progress Notes and Flowsheet documented the treatment (painting with betadine) P3’s toe and heal was provided on 05/28/2024, the day of the order, and then on 06/02/2024, 06/03/2024, and 06/04/2024. There was no evidence the treatment was provided as ordered on 05/29/2024, 05/30/2024, 05/31/2024 or 06/01/2024. The wound was first measured by the Wound Consult Nurse on 06/04/2024, and there were no pictures taken. 4) On 06/05/2024 at 07:30 AM, during an interview with RN1, he described his practice regarding admissions and wound care, including positioning. RN1 said the facility policy is to have a second RN confirm the skin integrity assessment on all new admissions. He went on to say they have a camera and tape measure to use and document wounds. RN1 said it is the responsibility of both the CNA and Nursing staff to turn patients. Who ever actually turned the patient should do the documentation and include what position the patient was in. He explained the computer had options for staff to choose. RN1 said they did not need an order to turn a patient because “it is standard of care to turn every two hours if they are at risk for pressure ulcers.” Reviewed RN1’s admission note for P2, which documented “skin wise, pt has a stage 2 excoriation to the coccyx. ...” When asked what he would expect to see for documentation of turning, he said it should be done every two hours and documented in the flowsheet. On 06/05/2024 at 08:30 AM during an interview with the Wound Nurse (WN), she said she was new to the facility and her role was to consult on wounds and make recommendations, but doesn’t do the daily wound changes. She said it is the admission nurse that does the first measurement and takes the picture. The WN said a Physician order must be obtained for wound care and dressing changes. She said if a patient has a coccyx/sacral wound, the standard of care would be to still rotate the patient supine, but offload the wound area with a wedge. The WN confirmed it is the expectation the specific position should be documented to include offloading. On 06/06/2024 at 10:00 AM, during an interview with CNA1, she said the usual practice is to turn patients with high risk every two hours. She explained the aides are told in report who needs to be turned. CNA1 went on to say most of the time they have a routine on her floor and usually rotate patients on the “even numbers.” She said they are suppose to document right away after they turn someone, but sometime the aides forget to chart. CNA1 said if the patient is on a special mattress, they do not have to turn the patient, but if they are on a regular bed, they do. 5) Reviewed the facility policy titled “Skin: Photo Documentation of Pressure Injury on Admission, Transfer or Discharge reviewed 08/26/2021. The policy included: “ All patients presenting with sDTI (suspected deep tissue injury) or pressure injuries will be photographed within 4 hours of admission.” “Place the measuring guide next to the patient’s wound and take a digital photo .” “Points of Emphasis” included: “The measuring guide identifies accurate wound size.” Appendix A to the policy was a sample picture of the measuring guide which included handwritten “Site, Laterally.” The standard of care for measuring wounds is to measure length (head to toe), width (lateral), and depth.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 39853 Based on record review (RR), and interviews, the facility patient care planning process does not meet the standard of practice. Five out of a sample size of five patient’s (P) interdisciplinary care plans were incomplete, and did not include interventions and represent the patients overall condition. As result of this deficiency, the facility individual patient care plans (CP)s are not detailed, well-structured/organized with clear strategies, tasks for the care team to ensure consistent and personalized care for the patients to meet their highest level of health and well being. Findings included: 1) P1 was a 79 year old male who was admitted to the hospital on 06/01/2024 for cellulitis of the left arm. He had been seen in the Emergency Department (ED) for swelling and redness to the arm 05/21/2024 and prescribed antibiotics. P1 saw his Primary Care Provider (PCP) on 05/29/2024 and prescribed an additional antibiotic. On 06/01/2024 he returned to the ED and was admitted. P1’s was being bedbound, due to mobility issues. He also had a wound on his sacrum prior to admission and was incontinent both bowel and bladder. His family helps him with his Activities of Daily Living (ADL’s). RR of P1’s medical records revealed the following: Admission History and Physical (H&P), 06/01/2024 08:57 PM included: “-Elevate LUE (left upper extremity)” “ #Grade 2 sacral decubitus ulcer PRESENT on Admission...” “ #Bedbound Unclear why the patient has had mobility issues since last admission. MRI of thoracic and lumbar spine completed on March 2023 and did not show evidence of spinal stenosis. ... He has had sparse follow-up with PT (physical therapy) so some or all of this may be due to deconditioning. ...” “Housekeeping - DVT (deep vein prophylaxis)” Wound Care Consult 06/02/2024 included: - Coccyx pressure injury stage 2. “ 1. ...Recommend zinc skin barrier with bordered foam dressing daily/PRN (as needed) for soilage and ...mattress P-500 (helps relieve pressure).” - Bilateral gluteal /sacral MASD (moisture associated skin damage- ... Recommend zinc barrier with bordered foam dressing/PRN per soilage ...” Orders 06/03/2024 09:24 AM included: - “Turn and Reposition frequently” -“ Specialty Bed” Care Plan: The facility CP is on a paper form titled “Interdisciplinary Plan of Care.” The form has four columns: 1) “Date, Initials Discipline, 2) “Focus”, 3) “Goals Desired Outcomes”, and 4) “Status Resolved date initials.” P1’s CP initiated on 06/02/2024 included: Focus: “Cellulitis” Goal: “will be treated w/(with) ordered Abx (antibiotic).” Focus: “Skin integrity”: Goal: “Open wounds to buttocks will show improvement/heal” Focus: “Safety” Goal: No injuries during hospitalization.” Focus: “Pain” Goal: Adequate Pain relief with ordered analgesia” Revision 06/03/2024: Focus: “ Integumentary/wound” Goal: “show evidence of healing & prevent worsen” Focus: “Nutrition” Goal: Pt to consume 1-50% of meals this admission.” All goals were marked documented as resolved with date of discharge 06/04/2024 The CP failed to include strategies and interventions for the care team to implement to meet P1’s goals. The CP did not include the following that was standard of care or ordered: - Cellulitis, the CP should include 1) elevate arm on pillow and 2) monitor for redness and swelling. - Skin integrity, the CP should include 1) repositioning q two hours or frequently, offload when supine, 2) air loss bed and 3) wound care/dressing. - Mobility: The CP did not include the important fact that P1 was bedbound, or what assistance he needed with ADL’s or PT/OT goals. There was an order for up in chair, which should be in the CP, as well as if he required one or two person assist. -P1 risk for DVT should be included in the CP with intervention of sequential compression device. -P1 had an order to monitor Intake and Output, which should have been included in the CP. -P1 was incontinent of Bowel/Bladder, which was not included in the CP. 2) P2 is a 97 year old female with a history of Stage 4 Chronic Kidney Disease, hypertension, and anemia. She and her family decided against dialysis and were referred for palliative care. P2’s primary language was Ilocano. She required assistance in all ADL’s and has a pressure ulcer due to significant weight loss and poor oral intake. She had been working with physical therapy (PT) at home, but having difficulty walking prior to coming to the ED on 03/08/2024 with shortness of breath and weakness. RR of P2’s medical records revealed the following: Admission History and Physical (H&P), 03/09/2024 01:36 AM included: “... Right buttock stage II pressure ulcers...” “-Wean off BIPAP (bilevel positive airway pressure machine for breathing assistance) as tolerate, ...Foley insertion” Orders: 03/09/2024 Sequential Compression Calf while in bed 03/09/2024 Activity as tolerated 03/09/2024 Aspiration precautions 03/09/2024 NPO (nothing by mouth) 03/11/2024 Dysphagia (difficulty swallowing), Pureed diet 03/11/2024 Ambulate with assist 03/11/2024 Specialty bed. 03/11/2024 Head of bed, Elevate 30 degrees 03/12/2024 Turn and reposition , every two hours. 03/13 /2024 Apply Z guard to pt’s coccyx. At this time please do not apply any foam dressing. CP included: 03/09/2024 Focus: Swallowing Goal: “Pt will tolerate least restrictive diet.” 03/10/2024 Focus: Fall Risk Goal: Zero falls 03/10/2024 Focus: DVI Risk Goal: Zero DVI 03/10/2024 Focus: Hemodynamics Goal: Zero arrhythmia’s, (illegible) will trended down [sic], Zero CP (chest pain), HR/BP controlled, MAP (mean arterial pressure) >65. 03/10/2024 Focus: CAUTI (catheter associated urinary tract infection) Goal: Zero CAUTI 03/11/2024 Focus: Nutrition, Goal: “Follow Nutrition POC (plan of care), pt to tol (tolerate) po (oral) diet.” 03/12/2024 Focus: Skin Integrity Goal: “Pt’s skin & coccyx area will be healed within 2 weeks” 03/13/2024 Focus: HTH (Hypertension), Goal: Pt will have stable BP (blood pressure) during hospitalization within 2 weeks” 03/14/2024 Focus Na Level (down), Goal: “ Pt will have stable Na level (135-142) during hospitalization (within 1 week) The CP failed to include any interventions or strategies to obtain the goals. P1’s PU was present on admission (03/09/2024), but was not put in the CP until 03/12/2024. Important information missing included, but not limited to: - Focus:Communication, barrier due to Primary language being Ilocano. Intervention should be when to use an interpreter. - P2 was on heparin and should be noted in CP to monitor for bruising and bleeding. - Dysphagia (swallowing) interventions of head of bed elevated 30 degrees, and specific diet (NPO to Pureed) - Respiratory focus with interventions of administration of oxygen as ordered with notification of Provider if outside established targets for oxygen saturation. - Skin integrity focus should include the repositioning, specialty bed and dressing change - DVI intervention should include sequential compression device while in bed. - The CP did not include P2 had a pacemaker. - Mobility goal to include ambulate with assist, - CAUTI interventions that may include routine flushes, place bag below bladder, off floor, ensure unobstructed urine flow and no kinks in tubing, verify continued need daily. 3) P3 is a 64 year old male with a history of surgery for Left hip fracture with chronic pain. He is on dialysis for end stage renal disease (ESRD). P3 presented to the ED on 05/26/2024 for generalized weakness, diarrhea and shortness of breath (SOB). He was admitted with diagnosis of diarrhea, pneumonia and L hip hardware failure. RR of P2’s medical records included the following: Initial Nursing assessment of skin integrity dated 5/26/2024 at 10:39 PM documented “Black, Necrotic” tissue to the left middle toe, and “Necrotic” to the right heel. Orders: 05/26/2024 Isolation (contact) rule out C-difficile infection (viral illness) 05/26/2024 Sequential compression device 05/26/2024 “Strict Intake and Output, q4H (every four hours)” 05/26/2024 “Ambulate with assist” 05/26/2024 “Head of bed, elevate 30 degrees” 05/26/2024 “Reposition and turn frequently” 05/26/2024 “Aspiration precautions” 05/26/2024 “Non weight bearing (on his L hip)” 05/26/2024 “ No BP/IV/Labs Left Arm...” 05/08/2024 “Dysphagia Minced (diet)/ Moist Thin/Regular Liquids, Restrict fluids to 1500 ml/day ...” 06/01/2024 “Pls (please) apply EMLA (local anesthetic) cream to left arm AVG (arteriovenous graft) then cover with clear plastic 1.5 hrs prior to hd (hemodialysis) Care Plan: Review of P3’s CP revealed the following: 05/26/2024 Focus: Diarrhea Goal: Zero diarrhea 05/26/2024 Focus: Mobility Goal: increase mobility 05/26/2024 Focus: Zero pain Goal: Zero pain 05/26/2024 Focus: SOB Goal: Zero SOB 05/26/2024 Focus: Safety Goal: Zero falls or injuries 05/26/2024 Focus: DVT Goal: Zero DVT during hospitalization 05/27/2024 Focus: Fluids and Electrolyte balance Goal: “Provide HD 3x/wk (three times per week) + PRN” 05/28/2024 Focus: Integumentary/wound Goal: “Show evidence of healing” 05/28/2024 Focus: Nutrition Goal: “ pt to tol ...(illegible) The CP did not include interventions. Patient specific information not included in the CP include, but not limited to: - P3 was diagnosed with pharyngeal dysphasia on 05/28/2024. The CP was not revised to include dysphagia with interventions as ordered that included aspiration precautions, head of bed elevated 30 degrees or the minced diet as ordered. - Skin integrity identifying the necrotic skin was not added to CP timely. Identified 05/06/2024, but not added until 05/28/2024. Treatment ordered included repositioning, off- load heals in bed and paint daily with Betadine. These interventions were not added to the CP. 4) P4 was a 97 year old female with medical history of chronic kidney disease (CKD), Type 2 Diabetes (T2DM), Hypertension, hypothyroidism and GERD (gastroesophageal reflux disease). At baseline, she ambulates with a cane. P4 presented to the ED on 06/01/2024 with weakness, and admitted with diagnosis that included heart failure with preserved ejection fraction (heart pumping chamber unable to fill properly), hypertension, bradycardia (slow heart rate), 1st degree heart block, GERD, T2DM, CKD, and anemia. Care Plan: Review of P4’s CP revealed the following: 06/01/2024 Focus: “hemodynamic instability’ Goal: “hemodynamically stable prior to transfer to ICU.” 06/01/2024 Focus: safety Goal: “safety maintained throughout hospitalization.” 06/01/2024 Focus: fall risk Goal: Zero Falls 06/01/2024 Focus: Pain Goal: “0/10 pain” 06/02/2024 Focus: Nutrition Goal: Pt total >75% tray 06/04/2024 Focus: ADLs & functional transfers Goal: “to complete ADL’s w (with)/... illegible handwritten entry. The CP failed to include any interventions or strategies to obtain the goals. Interventions ordered that should be in the CP include the following: Intake and Output, Head of bed elevated and sequential compression device. 5) P5 was an 89 year old male with a history of chronic respiratory failure on home oxygen. His medical history includes atrial fibrillation, hypertension, CABG (open heart surgery), stroke, Parkinsons and dementia. He has severe functional disability due to the Parkinsons and requires moderate-maximum assistance, but is able to eat on his own. P5 takes Elequis (blood thinner) for atrial fibrillation. He presented to the ED on 06/02/2024 with SOB and declining O2 (oxygen ) saturation, and was admitted with the diagnosis of pneumonia. Orders included, but not limited to: 06/02/2024 Sequential Compression Knee Length 06/02/2024 Apixaban (elequis) 5 mg tab oral BID (twice a day) 06/03/2024 aspirin 81 mg, oral one daily 06/04/2024 Ambulate with assist 06/04/2024 Up to chair with assist only 3 times a day. 06/04/2024 Head of bed, elevate 30 degrees 06/04/2024 Keep O2 Sat > = 95, May titrate. 06/04/2024 Precaution Fall P5’s CP included: 06/02/2024 Focus: safety Goal: Zero fall 06/02/2024 Focus: SOB Goal: off oxygen, normal breath sounds 06/02/2024 Nutrition Goal: Pt to consume >/= 75% of meals this admission The CP failed to include any interventions or strategies to obtain any of the identified goals. Interventions ordered that should be in the CP include the following: -Intake and Output -Head of bed elevated -Sequential compression device. -Mobility, with interventions of what assistance for ambulation -Anticoagulant with intervention to monitor for bruising and bleeding 6) On 06/04/2024 at 04:00 PM, during an interview with the Patient Care Coordinator (PCC)1, inquired what the process was for development of the CP. She said the admission nurse initiates the CP after the initial assessment. She went on to say they use the paper form and kept in hard chart. The PCC1 said the nursing staff document in the progress notes and use the DAR (Data, Action, and Responses) structured format and said patient interventions should be documented there. She admitted this documentation was not always consistent and that it was the standard of care that interventions should be included in the CP, and part of the CP process. On 06/06/2024 at 09:00 AM, during an interview with the Nurse Educator (NE)1, she explained the facilities process for care planning and said all disciplines should be documenting on the one “hard chart (paper) CP. The NE acknowledged there was no space on the form to trigger staff to write interventions for the goals, but that it is taught in orientation and sample CP’s. She used the example of patient with skin breakdown, and said the CP should include positioning and what specifically is meant by that. On 06/05/2024 at 10:00 AM, during an interview with a Certified Nurse Assistant (CNA)1, she said they do not use the CP and that they get report from the previous shift at shift change what each patient’s needs are, which includes positioning, mobility and other care they need. 7) Reviewed the facility policy titled Nursing Process, Assessment and Care of Patients reviewed 08/16/2021, which included the following: “The nursing process will be followed to provide a complete, and organized medical record to ensure safe patient care and quality patient outcomes.” “Step 2: Identification of Problem. Patient problems will be identified bases on signs and symptoms of the patient’s response to their illness, any risk factors, as well as the assessment data that has been collected. Problems will be listed on the Interdisciplinary Plan of Care form (IDPC).” “Step 3 ...Identified care needs and Standards of Care will serve as guidelines in developing the patient’s individualized plan of care.” “Step 4 Intervention” “1. Nursing interventions will: “Be determined by established policies, procedure, protocols, and standards of care. ...” “Documentation” “1. The appropriate forms will be used to document: ...Plan of care...” “3. Charting format and requirements: ...The FOCUS note using DAR format will be used to document assessments, nursing interventions and plan of care.” Care plans are a vital part of the nursing process. They provide a centralized document of the patient’s condition, diagnosis, the healthcare team goals and interventions to meet those goals and structured to capture all important information for the team in none place. Because the information is centralized with updates, the CP ensures everything important is documented and available to all team members. Without the interventions included in the CP , the communication is disjointed and located in different patient records.”