HospitalInspections.org

Based on interview, record review and policy review, the facility staff failed to individualize care plans to ensure potential care needs and response to interventions are addressed for four (#2, #3, #4 and #5) of four patients reviewed. This had the potential to affect all patients. The facility census was four.

Findings included:

1. Review of the facility policy revised 12/10 titled "Nursing Process", showed the following direction:
-That every patient will have a plan of care
-The patient problem will be used in all situations that apply. The plan of care must address the interventions.
-Ongoing patient and significant other needs will be addressed including: emotional, psychosocial developmental, educational, self-care, and discharge.

2. Record review of the History and Physical (H&P) of Patient #2 showed the patient was admitted to the facility on 01/21/12 for difficulty in breathing and a diagnosis of pneumonia. Further review of the record showed the patient was on oxygen and oxygen saturations (a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) were ordered by the physician.

Record review on 01/24/12 of the Plan of Care for Patient #2 initiated on 01/21/12 did not include individualized interventions of oxygen supplement or oxygen saturations.

3. Record review of the H&P of Patient #3 showed the patient was admitted on 01/23/12 for hip and pelvic pain with a diagnosis of pelvic fracture and identified as a high fall risk.

Record review on 01/24/12 of the Plan of Care for patient #3 initiated on 01/24/12 showed no individualized interventions for risk for falls such as yellow sign on the door, wrist band, yellow non skid socks, the bed in low position or call lights within reach.

4. Record review of the H&P of Patient #4 showed the patient was admitted to the facility on 01/12/12 for rehabilitation after a fracture of the right tibia and identified as a high fall risk.

Record review of the Plan of Care for Patient #4 initiated on 01/12/12 showed no individualized interventions for high fall risk such as yellow sign on the door, wrist band, yellow non skid socks, the bed in low position or call lights within reach.

5. Record review of the H&P for Patient #5 showed the patient was admitted to the facility on 01/23/12 for physical therapy after a left hip replacement. The H&P also showed the patient's hemoglobin (red blood cells that carry oxygen to the body) was 9.7 gm/dl (normal for men 14 - 18) and was receiving Warfarin (a anticoagulant used as a preventative for blood clots).

Record review on 01/24/12 of the Plan of Care for Patient #5 showed no care plan for interventions related to the decreased hemoglobin or for the risk of bleeding related to the drug Warfarin.

During an interview on 01/24/12 at 9:50 AM Staff I, Registered Nurse, stated that there are no interventions specific to Patient #2's use of oxygen or the oxygen saturations ordered. Staff I stated that the individualized interventions were found under the "tasks" tabs of the patient's electronic record and not under the care plan of the patients.