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CHRISTUS SPOHN HOSPITAL CORPUS CHRISTI
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based upon reviews of thefacility's policies and procedures, clinical records, and interviews with the facility's staff, the facility's staff failed to provide a safe setting.
Findings:
1. Reviewed clinical records and facility policies and procedures and found that staff failed to provide a complete assessment as required by current standards of practice for the condition the patient was treated for.
2. Interviewed Director of Quality and Licensed Clinical Social Worker who could not find evidence of a complete assessment as required by the current standards of practice, they both agreed that the assessment was not completed.
No Description Available
Tag No.: A0267
Based upon reviews of the Facility's policies and procedures, Quality Assurance records, and interviews with the facility's staff, the facility is not currently measuring or tracking quality indicators as they relate to proper assessments as requried by current standards of practice.
Findings:
1. Reviewed quality assurance data and could not find evidence of faciltiy currently tracking quality indicators related to the completion of required assessments that are required under current standards of practice.
2. Interviewed Director of Quality and Director of Case Managment, both agreed that the facility could not provide evidence of tracking quality indicators that measure or analyze the completion of required assessments are required by current standards of practice.
NURSING CARE PLAN
Tag No.: A0396
Based upon reviews of the facility's policies and procedures, clinical records, and interviews with the facility's staff, the facility staff failed to keep current a nursing care plan.
Findings:
1. Reviewed clinical record and could not find a current care plan that included the discharge planning of the patient, to include planning for discharge to meet post-hospital needs.
2. Interviewed Director of Quality and she agreed that the facility's staff failed to complete and keep current a nursing care plan to include complete assessment for the condition the patient was treated for, and also failed to provide post-hospital needs assessment. Staff could not provide evidence of compliance with this regualtion.