HospitalInspections.org

Based on review of medical records, facility policies/procedures, meeting minutes and staff interviews, the facility failed to ensure he nursing staff developed and kept current, a nursing care plan that addressed the admitting diagnoses and other significant conditions that required interventions for each patient, in ten of twenty-three sample records (#1, #3, #5, #11, #12, #13, #19, #21, #22, and #23). The failure created the potential for a negative patient outcome. The findings were:

Policies/Procedures Review:
Review of facility policies and procedures and related forms currently being utilized to develop/update nursing care plans for each individual patient were reviewed. The reviews revealed the facility utilized at least four different forms of nursing care plan development. Review of medical records revealed different combinations of the forms were being used from patient to patient and between units. The types of care plans utilized were the following:

1. "Multidisciplinary Planning Record" on the Adult Admission History and Assessment Form, which contained a blank grid to be filled out with the following sections: "Care Concern-as identified by care plan" "Date," "Daily Goal," and "Interventions." The policy/procedure "Patient Assessment and Reassessment, Adult Guidelines" stated the following, in pertinent parts:
"B. RN to Complete...
2) Care concerns are Nursing Care Plans, Pathway, and referrals, which correspond to each body system review and will be used to prioritize the care of the patient. The Care Planning process will take into consideration the patient's goals and the interventions necessary to meet the goals..."

2. "Patient Care Plan/Pathway" forms which were a set of care plan pathways for specific patient conditions, diagnoses. The policy/procedure "Patient Care Plan/Pathways" stated the following, in pertinent parts:
"Purpose Statement: Patient Care Plan/Patient Care Pathway is utilized as a guide to assess, plan, implement, and evaluate care. A Care Plan/Pathway is to be initiated by the Registered Nurse for each patient admitted. Utilizing data from the Admission Record/Patient History and Assessment or other assessment/reassessment data, the Care Plan/Pathway addresses the primary admitting diagnosis and/or additional problems that require new or revised interventions to promote or maintain the patient's optimal health. It is a communication tool for health care professionals promoting quality and continuity of care."
The policy/procedure required daily review and updating of the set of pathways being utilized, with additional pathways added, when appropriate, and goal/expected outcomes individualized/modified to meet the needs of the patient. Review of the pathway sets revealed the forms contained a list of related nursing diagnoses, goals and nursing interventions.

3. Specialty Unit Pathways were available to be utilized in some specialty areas including obstetrics and orthopedics. Samples of orthopedic pathways for "Total Knee Replacement" and "Hip Arthroplasty: Clinical Pathway" were provided for review. The pathways included a set of goals for the day of surgery, as well as each post-operative day. The elements of "tests," "activity," "treatment," "medications (pain)," "teaching" and "discharge planning" were present on each day, but had different goals and each area was designed to be individualized to the patient's needs by adding additional information in designated areas on the forms under each element.

4. Kardexes were also used to track short-term orders and treatments, as well as a large area on the back designed to be a permanent part of the medical record and was titled "Care Planning Record." That part of the kardex contained a blank grid with areas titled "date," "problem," intervention/action," "goal," and "resolved." The bottom of that part of the kardex also contained an area to document protocols and pathways being utilized for the patient. Statements from nursing meeting minutes (1/6/10) and nurse educator interview (1/12/10) stated the new Kardexes, with a permanent record section for "Care Planning Record" and Protocols/Pathways tracking, were to be utilized effective 1/4/10. Review of three open records (samples #21, #22, #23) on 1/12/10 revealed all three Kardexes were completely blank in those areas.

Medical Record Reviews:

1. Sample #1 was an elderly patient admitted on 10/3/08 who expired on 10/6/08. The patient presented to the emergency department with a chief complaint of bladder pain following an outpatient surgery. The patient's primary admitting diagnosis was urinary clot retention after resection of bladder tumor. Additionally, the patient had a diagnosis of Alzheimer's dementia. The patient required attentive care due to the patient's mental condition. A sitter was ordered and present during the patient's hospitalization. The patient had two care plan pathways: "Pain" and "Urinary Elimination, Altered." The care plans did not address fall risk, skin integrity, altered family processes, or cognitive condition and needs (particularly Alzheimer's).

2. Sample #3 was an adult patient admitted on 7/6/09 and discharged to the inpatient rehab unit on 7/10/09. S/he came to the hospital with new-onset lower extremity paralysis. The patient's new diagnoses included presumed transverse myelitis, urinary tract infection, and neurogenic bowel and bladder. Previously existing diagnoses included hypertension and coronary artery disease/dyslipidemia. The patient's only care plan was the "Activity Intolerance" pathway. The care plan was not specifically tailored to this patient, nor did it address the patient's other issues such as coping, skin integrity, impaired physical mobility, altered bowel elimination, or urinary elimination issues.

3. Sample #5 was an adult patient admitted on 7/8/09 and left Against Medical Advice (AMA) 7/9/09. S/he presented to the hospital after a fall and with acute alcohol intoxication. The patient's final diagnosis was subdural hematoma, status post fall. Some of the patient's additional diagnoses included hypertension, chronic renal insufficiency, diverticulosis, and anemia. No care plan of any kind was present for this patient, when possible issues to address were coping, deficient knowledge - alcohol and substances, fall risk, and neurological changes with monitoring needs.

4. Sample #11 was an elderly patient admitted on 10/3/09 who expired on 10/5/09. The patient presented to the emergency department and was diagnosed with an inferior infarction (heart attack). During the patient's stay, s/he required intensive care treatment, wrist restraints, cardiac catheterization, intubation and mechanical ventilation, an intraaortic balloon pump, and multiple continuous medications. The patient's only care plan was the "High risk for injury: Bleeding" pathway. The care plan did not address any of the patient's many other issues such as decreased cardiac output, ineffective airway clearance/pattern or gas exchange, or restraint monitoring/ care/ rationale for use.

5. Sample #12 was an adult patient admitted on 11/23/09 and discharged home on 11/26/09. The patient was transferred to the hospital from an outlying facility for treatment after a fainting episode and new traumatic subarachnoid hemorrhage. The patient's other diagnoses included coronary artery disease, congestive heart failure, chronic kidney disease, and hypertension. The patient had two patient care pathways present, which were "Fall, High risk for injury" and "Anxiety." There was no neurological care plan, despite a significant neurotrauma diagnosis.

6. Sample #13 was an elderly patient admitted on 11/25/09 and transferred to a skilled nursing facility on 11/28/09. The patient was admitted from an outlying hospital after a fall and temporary confusion. The patient was found to have cardiac arrhythmias at the outlying hospital and during the course of his/her admission. Diagnoses for the patient included third-degree atrioventricular block, status post fall, urinary tract infection, chronic obstructive pulmonary disease, pulmonary cyst with recurrent pneumonia, and hypertension. The patient had a cardiac pacemaker implanted during his/her hospital stay and unremarkable x-rays and CT scan. The patient had a "Cardiac output, Decreased" care plan pathway and one "Daily Teaching" sheet that educated about "fainting." There were no care plans to fall risk (patient also had a history of a seizure disorder), pain (present on admit due to fall), self-care deficit (evaluation of appropriate level of home care setting), or infection (urinary tract infection and pneumonia present).

7. Sample #19 was an adult patient admitted 12/23/09 and still an inpatient on 1/12/10, the day of survey. The patient's admitting diagnosis was right-sided pneumonia and the patient required intensive care treatment during his/her stay due to empyema, multiple chest tubes, low blood pressure requiring continuous medication, and intubation with mechanical ventilation. The patient received physical and occupational therapy, tube feeds, and continuous sedation during her/his hospitalization. The only care plan present was the "Ineffective gas exchange" pathway. The care plan did not address altered family processes (the patient's spouse/children live hours away), decreased cardiac output, activity intolerance (due to sedation & bedrest), nutrition (patient on tube feeds), skin integrity, or restraint monitoring/ care/ rationale for use.

8. Sample #21 was an elderly patient admitted on 1/9/10 and still an inpatient on 1/12/10, the day of survey. The patient was admitted with shortness of breath and diagnosed with systolic heart failure exacerbation. Contributing diagnosis for the patient included coronary artery disease with ischemic cardiomyopathy, diabetes mellitus, currently hyperglycemic (per History & Physical) and home oxygen requirement. The patient had two patient care plan pathways that were "Activity intolerance" and "Decreased cardiac output." The patient's chief complaint of shortness of breath was not addressed in the care plans. The care planning record on the new patient Kardex was blank as of 1/12/10.

9. Sample #22 was an elderly patient admitted on 1/6/10 and still an inpatient on 1/12/10, the day of survey. The patient was admitted with right facial pain and headache with numbness and diagnosed with an invasive right maxillary sinus neoplasm. The patient was chronically on warfarin due to a past stroke, had a history of depression, and underwent a biopsy done via right nostril on 1/8/10. The care planning record on the new patient Kardex was blank as of 1/12/10. The two present patient care plan pathways were "Pain" and "Impaired skin integrity: High risk for pressure sores." The patient's coping needs and depression history along with possibility of high risk for bleeding were not addressed.

10. Sample #23 was an adult patient admitted on 11/26/09 and still an inpatient on 1/12/10, the day of survey. The patient was admitted with increasing shortness of breath. The patient's admitting diagnoses included chronic obstructive pulmonary disease exacerbation, paraplegia, bronchospasm, respiratory infection, hypertension, congestive heart failure, and depression. The patient chronically took pain medication and had a gastrostomy tube. During the patient's hospitalization, s/he required intensive care treatment for mechanical ventilation and was diagnosed with Clostridium difficile, Methicillin resistant Staphylococcus aureus, and Vancomycin-resistant Enterococci, along with having three pressure ulcers. The patient had three care plan pathways present: "Knowledge deficit," "Ineffective breathing pattern" and "Impaired skin integrity: high risk for pressure sores." These pathways were not specifically tailored to this complex patient, nor were any pathways present regarding pain or infection, both significant issues for this patient. The care planning record on the new patient Kardex was blank as of 1/12/10.

Staff Interviews:

1. Chief Nursing Officer:
On 1/13/10 at approximately 8 a.m., the chief nursing officer was interviewed about the variety of care plan forms, the inconsistency of use and the failure of nursing staff to customize interventions, nursing diagnoses and expected outcomes when utilizing the nursing care pathway sets. S/he recognized the nursing department may be trying to require nursing documentation of care planning in too many areas, leading to the lack of documentation on some care planning forms. S/he stated the inconsistency of use was especially problematic for temporary/float nursing staff who do not know the patient from day to day and are dependent on an accurate care plan, found in a consistent location in the record, to understand the needs of the patients. S/he stated they would look at all they are doing and attempt to consolidate and further standardize their care planning efforts.

2. Telemetry Nurse:
In an interview with a telemetry nurse on 1/12/10 conducted at approximately 1:30 p.m., s/he stated that care planning may be found in many areas, such as the new Kardex, the pathways, or the Daily Teaching print-outs. The nurse showed the surveyors examples of his/her use of the Daily Teaching format with his/her patients. Review of his/her patient's open record and another open record on the unit revealed inconsistency among nurses in use of the Daily Teaching format to document care plans. S/he stated that the location of the care planning information was often dependent on which nurse was doing the documentation.