HospitalInspections.org

Based on medical record reviews, facility policy reviews, facility job description reviews, and staff interviews; the facility failed to ensure that a care plan was developed for 1 sampled patient (Patient 1), and failed to keep the careplans current to reflect the patients' changing needs for 2 sampled patients (Patients 2 and 17) from a sample size of 20 inpatient records reviewed. This failure had the potential to affect all patients. The facility census was 1 inpatient.

Findings are:

A. Review of the facility job description for the position of Registered Nurse (RN), with an approval date of 7/24/14), directs, in the section titled "Essential Job Duties and Responsibilities", "Develops plan of care based on the assessment, implements and documents the plan of care, updates care plan daily as indicated."

An interview with RN Director of Medical Services was completed at 2:10 PM on 5/18/2015, which revealed the facility did not have a policy on care planning for inpatients.

B. Patient 1 was admitted on 4/22/15 with a diagnosis of abdominal pain, nausea and vomiting. It was known from previous admissions that the patient had large gallstones with chronic cholecystitis (inflammation of the gall bladder). It was determined that it would be necessary to perform a Laparoscopic Cholecystectomy (surgical removal of the gall bladder using a scope with camera procedure). The surgery was performed on 4/23/15.

Patient 1 had no complications from the surgery; however, it was documented that this patient had pain with nausea and vomiting both prior to and after the surgery. Patient 1 was discharged to a swing bed on 4/29/15.

In review of the chart with the Director of Medical Services on 5/18/15, no care plan was found for this admission. On 5/18/15 at 2:10PM, the Director of Medical Services confirmed that no care plan had been developed for this admission to meet this patient's care needs. He/she responded that there should have been a care plan developed to address pain, surgical wound/risk of infection, and something to address the nausea and vomiting.


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C. Medical record review for Patient 2 revealed this patient was admitted on 5/8/15 and discharged to a nursing home for Hospice care on 5/14/15. History and Physical dated 5/8/15 noted the patient was admitted with fever, diabetes, dementia and hypertension. The Plan of Care developed on admission by a Registered Nurse (RN) on 5/8/15 included Risk for Falls and Impaired Memory. Review of surgical consult (dated 5/11/15) noted that the patient's fever had improved but the patient began to complain of peri-rectal pain. Radiological testing found the patient had a large peri-rectal abscess (a pus-filled cavity that develops in the anal opening). The patient had surgery on 5/11/15 to open and drain the abscess. A drain was left in to allow for further drainage. Ordered treatments by the physician for nursing included a urinary catheter to dependent drainage and washing the area twice daily with soap and water.

Staff interview with RN-H on 5/15/15 at 11:15 AM, confirmed the Plan of Care was not updated to reflect the patient's post surgery needs. RN-H related that the Plan of Care should have had been developed with interventions related to skin integrity or risk for infection due to the rectal abscess repair and drainage.

D. Medical record review for Patient 17 revealed that this patient was admitted on 12/4/14 and discharged on 12/10/14. Admitting diagnosis was noted as Insulin Dependent Diabetes and Cellulitis (a bacterial infection of the skin which goes into the layers of the skin and the fat) of the lower legs. The physician orders included dressing changes to the lower legs and antibiotics. Nurses notes on admission noted the patient had a fever of 100.4 Fahrenheit. Review of nursing documentation during the patient's stay noted the patient's legs were red and had drainage present from ulcerative lesions on the lower legs. Review of the Plan of Care developed on admission identified the patients needs as Risk for Falls and Activity Intolerance. There was no documentation on the care plan or interventions on the care plan that identified or addressed the patients needs related to the Cellulitis and wound care.

Staff interview with RN-H on 5/15/15 at 9:30 AM confirmed the Plan of Care was not updated or developed to include the patient's skin integrity issues.

Based on record review, personnel policy review and administrative staff interview, the facility failed to check the State Nurse Aide Registry for any adverse findings for 2 of 2 (Phlebotomist-C and Medical Lab Technician-G) staff prior to hire. The facility did not check the Registry for unlicensed direct care staff unless the staff person was a Nurse Aide. Without checking the Registry the facility could hire an individual who had a finding entered in the Registry concerning abuse, neglect, mistreatment of patients or misappropriation of their property. This finding has the potential to place all patients at risk of potential abuse who are cared for by an unlicensed direct care staff member that is not a Nurse Aide. The facility Swing Bed census was zero at the time of the survey. Findings are:

A. Record review of the Personnel file for Phlebotomist-C (A phlebotomist draws blood from patients for laboratory testing. Phlebotomists do not have a license to practice) revealed a date of hire as 10/6/14. The file, reviewed on 5/19/15, failed to find any evidence the facility had checked the State Nurse Aide Registry for any adverse findings.

B. Record review of the Personnel file for Medical Laboratory Technician (MLT)-G (A MLT is a unlicensed staff member who draws blood from patients and performs laboratory testing on) revealed a hire date of 4/7/14. The file, reviewed on 5/19/15, failed to find any evidence the facility had checked the State Nurse Aide Registry for any adverse findings.

C. Review of facility policy titled "Background Check & Post-Offer Employment 838.080.2" (originally dated 10/1/12 and updated 3/31/15) noted that Nurse Aide Registry checks were done only "if applicable." The policy identified that Nurse Aide Registry checks are done for any new hire "which possesses or requires a certified nurse aide or any position that assists patients the State Nurse Aide Registry must be checked. A copy of the verification is to be placed in the new hire file for all licensed and unlicensed direct care staff prior to the first day of employment. The policy further stated that the hospital "will not employ any person with an adverse finding on the Nurse Aide Registry."

D. Administrative interview with the facility Compliance Officer and the Human Resource Manager on 5/19/15 at 9:30 AM confirmed the facility did not perform Nurse Aide Registry checks on non-licensed patient care personnel unless they are a Certified Nurses Aide. The interview also confirmed that Phlebotomist-C and MLT-G did not have a check of the Nurse Aide Registry. The staff confirmed both provide direct care to patients when doing blood draws.