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Based on interview and record review, the hospital failed to ensure the nursing staff developed an individualized nursing care plan to address the care needs of the patient with pain and pleural effusion for one of five sampled patients (Patient 4). This failure posed the risk of patient care and treatment were not appropriately provided to the patient.

Findings:

Review of the hospital's P&P titled Interdisciplinary Plan Of Care (IPOC) dated 11/16/22, showed the following:

* Policy: The hospital plans the patient's care, treatment, and services based on the needs identified by the patient's initial assessment, reassessment, and result of diagnostic testing. The Plan of Care is based on the patient's goal and the time frames, settings, and services required to meet those goals. Based on the goals established in the patient's plan of care, staff evaluate the patient's progress towards goals. The hospital revises plans and goals for care, treatment, and services based on the patient's needs.

* Procedure: Initiating a Plan of Care:

- Completion of the Nursing Assessment will trigger a suggested IPOC displayed on the order section of the patient's EMR.

- The nurse collaborates with the Interdisciplinary Care Team. A member of the care team may also identify, search, and select an appropriate IPOC.

- The Nurse/Interdisciplinary Care Team reviews goals and interventions and initiates the IPOC.

- The Plan of Care is individualized by for each patient based on medical diagnosis and actual or potential problems identified in the initial assessment and reassessment during hospitalization. Patient specific goals and/or patient specific interventions should be used to individualize the IPOC.

- The Nurse or Interdisciplinary Care Team updates outcomes and interventions.

On 11/18/24 at 1534 hours, an interview and concurrent review of Patient 4's medical record was conducted with RN 5, Nurse Manager 3, and Director 2.

Patient 4's medical record showed Patient 4 was admitted to the hospital on 11/14/24.

Review of Patient 4's H&P examination dated 11/14/24 at 0032 hours, showed Patient 4 had progressively worsening intermittent coughing spells over the past several weeks. The Assessment/Plan section showed the patient was found to have progressively enlarged right pleural effusion on the chest X-ray. The patient was potentially to have thoracentesis.

Review of the Procedure Note Required Details dated 11/14/24 at 1130 hours, showed a chest tube insertion was performed for the patient.

Review of RN's pain assessment for Patient 4 showed on 11/14/24 at 1612 hours, Patient 4's pain level was six (on a pain scale from zero to 10, zero means no pain and 10 means the worst possible pain); the pain location was the right abdomen; and Patient 4's acceptable pain level was zero.

Patient 4's medical record showed Patient 4 was given oxycodone (a pain medication) 5 mg PO as needed for pain. Patient 4's pain level was reassessed on 11/14/24 at 1652 hours and the patient's pain level was zero.

Review of Patient 4's medical record failed to show documented evidence the nursing staff developed the plan of care related to pain, and the patient's large pleural effusion.

RN 5 confirmed there was no care plan developed for pain and for the patient's problem of pleural effusion.

Based on interview and record review, the hospital failed to ensure the nursing staff implemented the hospital's P&P related to recording the chest tube output for one of five sampled patients (Patient 4). This failure posed the risk of patient care and treatment were not provided appropriately for the patient.

Findings:

Review of the hospital's P&P titled Patient Care Documentation Guidelines (Inpatient) dated 2/8/24, showed in part:

* Policy: The hospital nursing staff will adhere to specified patient care documentation guidelines in the Inpatient Units, including assessment, reassessment, and documentation.

* Purpose: To outline patient care expectations and documentation requirements in the Inpatient Units.

* For the Telemetry Unit, the documentation of the intake and output is every 8 hours.

On 11/18/24 at 1534 hours, an interview and concurrent review of Patient 4's medical record was conducted with RN 5, Nurse Manager 3, and Director 2.

Patient 4's medical record showed Patient 4 was admitted to the hospital on 11/14/24.

Review of the Procedure Note Required Details dated 11/14/24 at 1130 hours, showed a chest tube insertion was performed for the patient.

Review of Patient 4's flowsheet for the chest tube outputs showed the following:

- On 11/15/25 from 0700 to 1859 hours (day shift), the chest tube output section was left blank.

- On 11/15/24 from 1900 to 0659 hours (night shift), the chest tube output was 280 ml, recorded on 11/16/24 at 0720 hours.

- On 11/16/24 for the day shift, the chest tube output was 480 ml; and for the night shift, the chest tube output was 760 ml.

- On 11/17/24 for day shift, the chest tube output was 100 ml; and for night shift, the chest tube section was left blank.

On 11/18/24 at 1557 hours, an interview and record review was conducted with RN 6. RN 6 stated he took care of the patient on 11/17/24 day shift. RN 6 was asked about the Patient 4's chest tube output on 11/17/24 night shift. RN 6 stated Patient 4's chest tube did not have output on the night shift of 11/17/24. However, there was no documented evidence on 11/17/24 night shift the RN documented that there was no chest tube output. The chest tube output was left blank. RN 5 and Nurse Manager 3 stated the nursing staff should document the chest tube output.

The findings were shared with RN 5 and Nurse Manager 3.