HospitalInspections.org

Based on interview and document review, the facility failed to ensure that three patients, Patient #2, Patient #3 and Patient #7, had a right to participate in the development and implementation of the Nursing Care Plan.


The findings include:


1.) During an interview with the Nursing Supervisor on 04/17/2019 at 1:40 PM, she was providing review of the medical record for Patient #2 and confirmed that the Nursing Care Plan was not initiated and all 11 pages of the Care Plan for Patient #2 were blank.


An interview was conducted with Employee K, RN on 04/17/2019 at 2:30 PM. She confirmed that she was caring for Patient #2, and she also confirmed that the Patient Care Plan, which included 11 total pages, were blank and did not even have a patient sticker on them. The Nurse reported that these care plans were supposed to be initiated at Admission. She reported that the nurse conducted the admission assessment with the patient. She confirmed the blank pages should have been part of the Patient Plan of Care. She stated that was how the nursing staff took care of the patient, and it was specific to the Patient Admission Diagnoses and problems. She stated, at admission, the nurse just did not have the time to write it down on paper.


A review of the medical record for Patient #2 confirmed that Patient #2 was admitted on 04/12/2019 at 3:40 PM. Patient #2 was admitted for diagnoses of "Respiratory and Vent management, and Rehab". Patient #2 was transferred to Curahealth for vent weaning on April 12, 2019. The Nursing Plan of Care was not initiated.


2.) An interview was conducted with Employee L, RN on 04/17/2018 at 2:35 PM. She confirmed for her patient, Patient #3, that she did not know where the care plan was. She confirmed that the patient was admitted on 04/12/2019 and that the Plan of Care identified problem areas and suggestions related to the patient's care. The patient's Plan of Care would include education for the patient and it should be updated and adapted to changes in the condition of the patient on a daily basis. She reported that getting the Plan of Care completed depended on how busy the shift was. She reported that updating the Plan of Care was not a top priority when you have to provide vent or trach care, or if something emergent occurred.


A review of the medical record for Patient #3 was conducted and it was documented that Patient #3 was admitted to the facility on 04/12/2015 at 9:10 PM.


A review of the History and Physical documented on 04/12/2019 by the attending physician at the facility documented that the patient was transferred from a community hospital following acute respiratory failure with aspiration pneumonia and bradyarrythmias, sustained acute cerebral vascular accident (CVA) approximately 2 weeks ago with dysphagia, sepsis, hypertension, and again documented CVA two months ago. Patient #3 was stabilized following IV antibiotics, Vancomycin and Zosyn and placement of tracheotomy on 04/11/2019.


The History and Physical also documented under the section for Plan: Will continue Patient #3 on full ventilator support. Assess chest x-ray upon admission with specialty. We will continue the patient on antibiotics, Zosyn therapy for aspiration pneumonia. Check MRSA, MRSA screening sputum culture upon admission to Curahealth. We will continue the patient on antipyretics, analgesics and transfer medications. We will consider internal medicine, neurological consult. Family does not want resuscitation.


A review of the Case Management Assessment for Patient #3 was conducted and documented initial assessment by Case Management on 4/15/2019 at 10:30 AM.


The Interdisciplinary Care Conference record was reviewed dated 4/17/2019 and documented under Nursing DNR: "No"; goals for safety fall prevention and low bed, Patient #3 was a fall risk. Case Management placement in skilled nursing facility (SNF). Other team goals were to include suction, trach, trach supplies, specialty mattress, wheelchair use and others. On the Interdisciplinary Patient Care Conference record; permanent part of the medical record was a section for "interdisciplinary team signatures." The only signatures on the Care Conference record included the Case Manager, Respiratory Therapy, Pharmacy, Nutritional services and Rehabilitation. The section for "Nursing" was blank, indicating nursing had not participated in the Care Conference.


A review of the "Patient Care Plan" was conducted for Patient #3 with Employee N, RN Supervisor on 04/17/2019 at 1:40 PM. The Care Plan did not have stickers and was confirmed entirely blank for Patient #3. Employee N, RN confirmed that she had just started addressing the importance of the Care Plan for the nursing team this morning.


3.) A review of the medical record for Patient #7 was conducted. It was documented that Patient #7 was admitted on 04/10/2019 at 6:10 PM. Patient #7 was a 63-year-old male. Patient #7 was admitted with past medical history of Diabetes Mellitus and he underwent a kidney/pancreas transplant in 2005. He was documented to have had atrial fibrillation, Protein C and S deficiency, Achalasia, and a history of intracranial hemorrhage after a fall while he was on Coumadin in October 2018. Patient #7 was medically complex and experienced multiple decline and recovery periods in health status. Patient #7 was transferred to Curahealth for "medical management."


A review of the Progress Notes drafted by the Internal Medicine Physician medically managing the progress for Patient #7 documented on 04/15/2019 the following: Recent labs - Sputum culture moderate oropharyngeal flora and the doctor's medical assessment of: chronic hypoxic respiratory failure; essential hypertension; neurogenic bladder; and achalasia, among a few other medical conditions. The medical Plan of Care specifically documented the following: Continuing weaning as per pulmonary; supportive care, Physical Therapy (PT)/Occupational Therapy (OT), and Speech Therapy (ST); follow-up with specialist recommendations.


A review of Patient #7's "Case Management Assessment" was conducted, dated 04/11/2019 at 12:00 PM. Patient #7's "Case Management Note" documented assessment conducted in patient's room and "other" at nursing station. Advanced Directive was documented at time as "in progress" and "wife makes decisions if patient is unable; per patient." Items documented as discussed included: Family Conference, Discharge Planning/Care Conference and "Recent Curahealth admission, transferred from Mayo for continued care. Frequent communication with wife". Under physical, medical risk factors was documented, "Inability to perform Activities of Daily Living (ADLs), medical and disease condition, multiple hospitalizations, chronic disease/condition and other as "trach collar". Documented Discharge Plan included to "In-patient Rehab, Brooks Rehab inpatient."


A review of the Nursing Care Plan for Patient #7 was conducted and the only thing documented on the 11-page Care Plan that was provided was the admission sticker for Patient #7. Every section on all 11 pages for Patient #7 for problem, intervention and goals was completely blank.


An interview was conducted with Employee N, RN Nursing Supervisor on 4/17/2019 at 1:40 PM. The RN Supervisor confirmed that she started rounding on nurses today to instruct them on the importance of the Care Plan. She confirmed that the Nursing Care Plan was to be used as the daily guide to managing the long term acute care patients, and she also confirmed that many of the nursing staff are overwhelmed and are just trying to keep up with the actual management of the patients. She reported that the Nursing Care Plans should have been completed at the admission; however, it can be quite busy; some nurses forget. She also confirmed that Patient #2, Patient #3 and Patient #7 have been at the facility long enough to have had Nursing Care Plan documentation and that they are blank for the three patients.


The Nursing Supervisor confirmed the Care Pan for Patient #3 was completely blank and she repeated during an interview on 04/17/2019 at 2:37 PM, "I was just going over the Care Pans for patients today. I was telling staff how important it was for us to get these completed." The House Supervisor also confirmed that the Care Plan for Patient #2 and Patient #7 had no documentation.


An interview was conducted with the Chief Clinical Officer (CCO) on 04/17/2019 at 2:45 PM and she confirmed that with three Plans of Care out of compliance, this problem must be bigger than meets the eye. She reported that she was going to address this right away; there was no excuse. She reported that the Patient Plan of Care should be completed right away and there was no excuse. The CCO provided a copy of the Policy and Procedures for completing the Nursing Care Plan.


A review of the facility provided policy generated from "Policy Stat" identification #4853846 was conducted. This documented "Nursing Care Plan" and "The Patient Care Plan starts as soon as the patient is admitted to the hospital and is continually updated throughout the patient's stay, in response to changes in the patient's condition and responses to the nursing interventions rendered. It documents all problem areas identified and is personalized for each individual patient." The procedure under Section A. documented, "The Plan of Care will be initiated by an RN after completion of the Admission Assessment."


No additional documentation supported completed Care Plans for the 3 sampled patients, Patient #2, Patient #3 and Patient #7.

Based on interview and medical record review; the facility failed to ensure that nursing staff developed and kept current a Nursing Care Plan for 3 ( #1, #2 and #3), of a total of 3 patients sampled for care planning.


The findings include:


1.) During an interview with the Nursing Supervisor on 04/17/2019 at 1:40 PM; she was providing review of the medical record for Patient #2 and confirmed that the Nursing Care Plan was not initiated and all 11 pages of the Care Plan for Patient #2 were blank.


An interview was conducted with Employee K, RN on 04/17/2019 at 2:30 PM. She confirmed that she was caring for Patient #2, and she also confirmed that the Patient Care Plan, which included 11 total pages, were blank and did not even have a patient sticker on them. The Nurse reported that these Care Plans were supposed to be initiated at admission. She reported that the nurse conducted the admission assessment with the patient; she confirmed the blank pages should have been part of the Patient Plan of Care. She stated that was how the nursing staff took care of the patient, and it was specific to the patient's admission diagnoses and problems. She stated, at admission, the nurse just does not have the time to document it on paper.


A review of the medical record for Patient #2 confirmed that Patient #2 was admitted on 04/12/2019 at 15:40 hours. Patient #2 was admitted for a diagnosis of "Respiratory and Vent management and Rehab." Patient #2 was transferred to Curahealth for vent weaning on April 12, 2019. The Nursing Plan of Care was not initiated.


2.) An interview was conducted with Employee L, RN on 04/17/2018 at 2:35 PM. She confirmed for her patient, Patient #3, that she did not know where the care plan was. She confirmed that the patient was admitted on 04/12/2019 and that the Plan of Care identified problem areas and suggestions related to the patient care. The patient's Plan of Care would include education for the patient and it should be updated and adapted to changes in the condition of the patient on a daily basis. She reported that getting the Plan of Care completed depended on how busy the shift was. She reported that updating the Plan of Care was not a top priority when you have to provide vent or trach care, or if something emergent occurred.


A review of the medical record for Patient #3 was conducted and it was documented that Patient #3 was admitted to the facility on 04/12/2015 at 9:10 PM.


A review of the History and Physical documented on 04/12/2019 by the Attending Physician at the facility documented that the patient was transferred from a community hospital following acute respiratory failure with aspiration pneumonia and bradyarrythmias, sustained acute cerebral vascular accident (CVA) approximately 2 weeks ago with dysphagia, sepsis, hypertension, and again documented CVA two months ago. Patient #3 was stabilized following Vancomycin and Zosyn, and placement of tracheotomy on 04/11/2019.


The History and Physical also documented under the section for Plan: Will continue Patient #3 on full ventilator support. Assess chest x-ray upon admission with specialty. We will continue the patient on antibiotics, Zosyn therapy for aspiration pneumonia. Check MRSA, MRSA screening sputum culture upon admission to Curahealth. We will continue the patient on antipyretics, analgesics and transfer medications. We will consider internal medicine, neurological consult. Family does not want resuscitation.


A review of the Case Management Assessment for Patient #3 was conducted and documented initial assessment by Case Management on 4/15/2019 at 10:30 AM.


The Interdisciplinary Care Conference record was reviewed dated 4/17/2019 and documented under Nursing DNR: "No"; goals for safety fall prevention and low bed; Patient #3 was a fall risk. Case Management placement in skilled nursing facility (SNF). Other team goals were to include suction, trach, trach supplies, specialty mattress, wheelchair use and others. On the Interdisciplinary Patient Care Conference Record; permanent part of the medical record was a section for "interdisciplinary team signatures." The only signatures on the care conference record included the Case Manager, Respiratory Therapy, Pharmacy, Nutritional services and Rehabilitation. The section for "Nursing" was blank, indicating Nursing had not participated in the care conference.


A review of the "Patient Care Plan" was conducted for Patient #3 with Employee N, RN Supervisor on 04/17/2019 at 1:40 PM. The Care Plan did not have stickers and was confirmed entirely blank for Patient #3. Employee N, RN confirmed that she had just started addressing the importance of the Care Plan for the nursing team this morning.


3.) A review of the medical record for Patient #7 was conducted. It was documented that Patient #7 was admitted on 04/10/2019 at 6:10 PM. Patient #7 was a 63-year-old male. Patient #7 was admitted with past medical history of Diabetes Mellitus and he underwent a kidney/pancreas transplant in 2005. He was documented to have had atrial fibrillation, Protein C and S deficiency, Achalasia, and a history of intracranial hemorrhage after a fall while he was on Coumadin in October 2018. Patient #7 was medically complex and experienced multiple decline and recovery periods in health status. Patient #7 was transferred to Curahealth for "medical management."


A review of the Progress Notes drafted by the Internal Medicine Physician medically managing the progress for Patient #7 documented on 04/15/2019 the following: Recent labs - Sputum culture moderate oropharyngeal flora and the doctor's medical assessment of: chronic hypoxic respiratory failure; essential hypertension; neurogenic bladder; and Achalasia among a few medical conditions. The medical Plan of Care specifically documented the following: Continuing weaning as per pulmonary; supportive care; Physical Therapy (PT)/Occupational Therapy (OT), and Speech Therapy (ST), follow-up with specialist recommendations.


A review of Patient #7's "Case Management Assessment" was conducted, dated 04/11/2019 at 12:00 PM. Patient #7's "Case Management Note" Assessment conducted in patient's room and "other" at Nursing Station, with spouse. Advanced Directive was documented at time as "in progress" and "wife makes decisions if patient is unable; per patient." Items documented as discussed included: Family conference, Discharge Planning/Care Conference and "Recent Curahealth admission; transferred from Mayo for continued care. Frequent communication with wife". Under "physical, medical risk factors" was documented, "Inability to perform Activities of Daily Living (ADLs), medical and disease condition; multiple hospitalizations; chronic disease/condition and other as "trach collar." Documented Discharge Plan included to "In-patient Rehab, Brooks Rehab In-patient."


A review of the Nursing Care Plan for Patient #7 was conducted and the only documentation on the 11-page Care Plan that was provided was the admission sticker for Patient #7. Every section on all 11 pages for Patient #7 for problem, intervention and goals was completely blank.


An interview was conducted with Employee N, RN Nursing Supervisor on 4/17/2019 at 1:40 PM. The RN Supervisor confirmed that she started rounding on nurses today to instruct them on the importance of the Care Plan; she confirmed that the Nursing Care Plan was to be used as the daily guide to managing the long term acute care patients, and she also confirmed that many of the nursing staff were overwhelmed and were just trying to keep up with the actual management of the patients. She reported that the Nursing Care Plans should have been completed at the admission; however, it can be quite busy; some nurses forget. She also confirmed that Patient #2, Patient #3 and Patient #7 have been at the facility long enough to have had Nursing Care Plan documentation, and that they were blank for the three patients.


The Nursing Supervisor confirmed the Care Plan for Patient #3 was completely blank and she repeated during an interview on 04/17/2019 at 2:37 PM, "I was just going over the Care Plans for patients today. I was telling staff how important it was for us to get these completed". The House Supervisor also confirmed that the Care Plan for Patient #2 and Patient #7 had no documentation.


An interview was conducted with the Chief Clinical Officer (CCO) on 04/17/2019 at 2:45 PM and she confirmed that with three Plans of care out of compliance, this problem must be bigger than meets the eye. She reported that she was going to address this right away; there was no excuse. She reported that the Patient Plan of Care should be completed right away and there was no excuse. The CCO provided a copy of the Policy and Procedures for completing the Nursing Care Plans.


A review of the facility-provided policy generated from "Policy Stat" identification #4853846 was conducted. This documented "Nursing Care Plan" and "The Patient Care Plan starts as soon as the patient is admitted to the hospital and is continually updated throughout the patient's stay, in response to changes in the patient's condition and responses to the nursing interventions rendered. It documents all problem areas identified and is personalized for each individual patient." The procedure under Section A. documented, "The Plan of Care will be initiated by an RN after completion of the Admission Assessment."


No additional documentation supported completed Care Plans for the 3 sampled patients, Patient #2, Patient #3 and Patient #7.