HospitalInspections.org

Based on interview, record review and review of hospital policy and procedures, it was determined the facility failed to develop and revise an effective nursing care plan for one patient (#1), in the selected sample of 10 patients.

Findings include:

A review of the Hospital Policy #610.20.18 "Nursing Process", last revised 06/09, revealed the nursing process planning phase included the development and modification of the client care plan and delivery of client/ patient care. The implementation phase of the nursing process included the provision of care to optimize the achievement of the health goals and records the information. The evaluation phase of the nursing process included the evaluation of the measures implemented, the investigation of compliance with prescribed orders and recording of the patient's response the treatment or care provided.

1. A record review revealed Patient #1 was admitted to the hospital on 01/14/13 with diagnoses to include Right Hip Fracture, Intertrochanteric Fracture, Anemia, Thrombocytopenia, Hypertensive Chronic Kidney Disease, Dementia, Coronary Atherosclerosis, Atrioventricular Block, 1st degree, Chronic Airway Obstruction, Hypothyroidism, Osteoarthrosis, Hearing loss, History of Penicillin Allergy, and Aortocoronary Bypass.

A review of the Plan of Care for Patient #1, dated 01/14/13, revealed the problems identified were Prepare Patient for Surgery, Impaired Skin Integrity, Pain, Altered Peripheral Tissue Perfusion, Impaired Mobility, and Self Care Deficit. The interventions provided for the problem Impaired Skin Integrity referred to the Wound/Drain Assessment related to the patient's surgery wound. There were no interventions to address the floating or checking of Patient #1's heels.

An interview with Registered Nurse (RN) #4, Charge Nurse, on 04/02/13 at 9:30 AM, revealed the care planning process began with the charge nurse providing a quick assessment or if time allowed, the full admission assessment. If the charge nurse did not complete the admission assessment, the assigned RN would complete the admission assessment. The admission assessment provided the information to develop the patient's plan of care. The hospital utilized a standardized care plan computer program and once the patient's diagnoses were identified the problems and interventions would automatically populate the care plan. The nurses would then edit to individualize the care plan for each patient. The RN explained "we float heels as a nursing judgement for a patient at risk or when we see a skin issue. We don't have to have a Medical Doctor (MD) order and it would not be on the care plan."

An interview with RN #3, on 04/03/13 at 1:00 PM, revealed the hospital developed the patient's care plan at admission and the same care plan was utilized throughout the patient's admission with the care plan revised after surgery to include the physician's post operative orders.

An interview with RN #2, on 04/03/13 at 7:15 AM, revealed floating heels was not a care plan intervention related to the diagnosis of hip fracture.

Interviews with RN #6 and RN #7, on 04/03/13 at 11:09 AM and 11:20 AM respectively, revealed the patient's admission assessment was completed within 5-10 minutes of arrival to the floor and the care plan is completed when the assessment is done. The RNs stated they had never placed "float heels" on the care plan.

An interview with the hospital Chief Nursing Officer (CNO), on 04/02/13 at 12:45 PM, revealed he would expect "float the heels" to be on the care plan and would expect the nurse who does the assessment to do the revision in the electronic medical records system.

An interview with the Director of Nursing Services (DON), on 04/02/13 at 1:45 PM, revealed the nursing communication function of the electronic medical records automatically "rolls" to the Kardex which was defined as a "cheat sheet" for the nurses that was updated every eight hours. The DON stated she would expect the MD order to be on the patient's care plan and she would expect the nurse who acknowledged the order to do the assessment.