HospitalInspections.org

Based on record review and interview, the facility failed to keep current a care plan for 2 of 4 patients with physical care needs (current patient #7 and discharged patient #9) resulting in increased risk of physical harm for all patients. Findings include:

Policy Review:
Facility staff were unable to find a policy that includes the regulatory requirement at A-0396 for keeping a current nursing care plan for each patient.

Record Review, patient #7:
On 1/15/14 at approximately 1:45 pm review of patient #7's clinical record revealed:
1. A "Medical Management" note dated 12/19/13 noting a diagnosis of "Type II diabetes."
2. A physician's note by staff M, dated 1/14/14, stating: "(Patient #7) had an episode of hypoglycemia last week, which insulin dose was adjusted."
3. There was nothing in patient #2's Care Plan regarding the diagnosis of Type II Diabetes Mellitus.

Interview:
On 1/15/14 at approximately 1:45 pm staff A confirmed all findings noted above and stated that patient #7 "should have a care plan for diabetes."

Record Review, patient #9:
On 1/16/14, from 9 am- 12 noon, record review revealed:
1. A "Safety Event Report, by "anonymous," dated 11/14/13 at 1:30 am stating: "pt (patient #9) punched concrete wall. Ice bag was applied and pt was mediated. No swelling noted, obvious dislocation or problems moving fingers." Since this note was "anonymous" it is impossible to identify the staff member who filed this report, assessed patient #9's hand injury and treated it with ice.
2. A nursing note by staff J, dated 11/14/13 at 3:57 am, stating that patient #9: "punched wall with right hand."
3. Patient #9's clinical record contained no documentation of the right hand being red or application of the ice treatment.
4. A "Consultation/review" note by staff B, dated 11/15/13, stating: "(patient #9) saw Dr. (staff L). He (staff L) wants to wait to see her (patient #9"s) hand." This note also states: "Patient states she punched a brick wall. Shoulder/hand hurt and she can't sleep."
5. A "Safety Event Report" follow-up note by the Unit Manager, staff K, dated 11/18/13, stating: "Pt (patient) stated she hit hand; seen by Dr..; no tests ordered by doctor at this time." It was not clear how the documented staff observation of this injury (by anonymous on 11/14/13) had changed from a witnessed observation to "patient states" that the injury occurred.
6. There was no documentation in patient #9's clinical record by the patient's doctor stating that he examined the patient's right hand prior to discharge.
7. Patient #9's care plan was not updated to address the right hand trauma sustained on 11/14/13.

Interviews:
1 On 1/16/14 at 9:40 am patient #9 stated that repeated requests for an x-ray of the injured hand were ignored by staff.
2. On 1/16/14 from 11-11:15 am staff B verified #4 and #6 (above).
3. On 1/16/14 from 9:50-11:15 am documentation (or lack of) referenced above in #1, #2, #3, #5, #6 and #7 were verified by staff A. Staff A stated that there is no requirement that staff members sign "Safety Event Report" forms. Staff A was unable to explain how "anonymous," who failed to document patient #9's injury assessment and treatment (on 11/14/13) would be held accountable. Staff A stated that patient #9's right hand assessment should have been documented in the patient's record.