HospitalInspections.org

Based on staff interviews and record review the facility failed for 2 of 2, (Patient #3 and #4), current inpatient records, with admission days greater that 14 days, to ensure that an comprehensive assessment was completed.

Findings:

1. Review of the medical record for Swing Bed Patient #3 revealed that a initial nursing assessment was completed on 09/01/2016 the day of admission. The same day nursing care plans were developed as part of the admission process. Concurrently, the physical therapy staff completed a physician therapy initial assessment, along with goal to achieve. The medical record also revealed weekly Patient Care Meetings for the patient. Review of the Patient Care Meeting revealed that the ongoing care provided to the patient was discussed along with discharge planning issues/needs.

Review of the medical record did not reveal that a comprehensive care plan with the goal of developing care plan based on identified patient care needs. Review of the medical record was conducted on 09/29/2016 and revealed that 28 days had passed from the date of admission.

2. Review of the medical record for Swing Bed Patient #4 revealed that a initial nursing assessment was completed on 08/17/2016 the day of admission. The same day nursing care plans were developed as part of the admission process. Concurrently, the physical therapy staff completed a physician therapy initial assessment, along with goal to achieve. The medical record also revealed weekly Patient Care Meetings for the patient. Review of the Patient Care Meeting revealed that the ongoing care provided to the patient was discussed along with discharge planning issues/needs.

Review of the medical record did not reveal that a comprehensive care plan with the goal of developing
care plan based on identified patient care needs. Review of the medical record was conducted on 09/29/2016 and revealed that 47 days had passed from the date of admission.

3. During a interview on 09/30/2016 at 10:00 AM, the Quality Director revealed that the facility used both the initial nursing and therapy assessments as the comprehensive assessments and the care plans for the patients were the care plans based on the initial assessments.