HospitalInspections.org

Based on document review and interview the facility failed to ensure that nursing staff maintained a current plan of care (POC) for 10 out of 10 (#1-#10) patients resulting in the potential for ineffective care.
Findings include:
On 4/8/14 and 4/9/14 during medical record review of patients #1-#10 it was found that the POC documentation on the document titled, "Inpatient services plan of care and significant events", lacked documentation of an ongoing reassessment of the POC based on changes in patient care needs, response to the nursing interventions implemented and if there were any revisions to the POC as needed.
On 4/8/14 at approximately 1200 during an interview with staff C when asked if there was any other documentation pertaining to the POC available for review, she replied, "No, the care plan is only on paper."
On 4/9/14 at approximately 1000 during an interview with staff D when queried as to the lack of documentation on the POC, she responded, "We know there's a problem and we have a computer program in progress, but it isn't scheduled to be launched until October of this year."