HospitalInspections.org

Based on record review and interview, the facility failed to ensure a nursing care plan was kept current for each patient in that, 1 of 10 patient's (Patient #1) care plan did not reflect accurate information for their 6/08/15 stay.

Findings Included

Patient #1 electronic record reflected, "6/09/15...urgent caesarean section...Plan of Care...Postpartum - Vag (Vaginal) Delivery: Signs and Symptoms of Potential Problems..."

During a telephone interview on 4/14/16 ending at 3:12 PM, Personnel #3 was informed of the above findings and asked to verify. Personnel #3 confirmed the findings and stated, "Wrong care plan for her."

Based on record review and interview, the facility failed to evidence a medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, in that, 2 of 10 patient's (Patient #1 and #6) electronic records did not evidence a history and physical no more than 30 days before or 24 hours after admission.

Findings Included

Patient #1's record reflected, "6/08/15 admission...6/09/15...cesarean...general anesthesia...11/20/14...prenatal history and physical..."

Patient #6's record reflected, "3/28/16 admission...cesarean section...9/17/15 prenatal history and physical..."

During an interview on 4/13/16 ending at 3:30 PM, Personnel #2 was informed of the above findings. Personnel #2 confirmed the findings and stated, "They (the staff) use the last date of the prenatal record instead of the date of the history and physical." Personnel #2 was asked if the last date of the prenatal record included an updated physical for each patient. Personnel #2 stated, "No."