HospitalInspections.org

Based on medical record review and nurse practice standards the facility failed to ensure the nursing care plan was developed with appropriate nursing interventions based on the needs of the patient and updated with new patient information as the patients conditions changed. 15 of the 20 patients charts reviewed did not have a nursing care plan updated with interventions and goals for the patient based on their nursing assessment.

Findings were:

Review of the Texas Nurse Practice Act §217.11. Standards of Nursing Practice, states, in part,
"(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ...
(D) Accurately and completely report and document:
(i) the client's status including signs and symptoms;
(ii) nursing care rendered;
(iii) physician, dentist or podiatrist orders;
(iv) administration of medications and treatments;
(v) client response(s); and
(vi) contacts with other health care team members concerning significant events regarding client's status."

In an interview with the Chief Nursing Officer on April 10, 2019 it was confirmed the current process in the hospital for patient care plans did not include nursing care plans that included documented interventions to provide care for the patient based on assessment or changes in assessment on the patients.