HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the nursing staff initiated a nursing plan of care for 1 of 7 medical records reviewed (Patient #5) and updated the nursing care plan for identified nursing care needs and interventions for 4 of 7 medical records (Patients #1, #3, #4, #6) reviewed.
Findings:

Patient #1
Review of the medical record for patient #1 revealed the patient was admitted to the hospital on 07/12/16 with the diagnosis of myocardial infarction. Further review of the record revealed the patient had a Foley catheter inserted on 07/15/16 with bloody urine noted. Review of the nursing plan of care revealed there failed to be documented evidence the nurse developed nursing interventions related to the patient's urinary status.

On 08/30/16 at 9:30 a.m., S6RN reviewed the electronic medical record with the surveyor and confirmed that a care plan was not developed to address the patient's urinary status and Foley catheter.

Patient #3
Review of the medical record for patient #3 revealed the patient was admitted to the hospital on 08/22/16 with the diagnosis of pneumonia. Review of the nursing plan of care revealed there failed to be documented evidence the nurse developed nursing interventions related to the patient's pulmonary functions.

Patient #4
Review of the medical record for patient #4 revealed the patient was admitted to the hospital on 08/29/16 with the diagnoses of acute appendicitis and appendectomy. Review of the nursing care plan revealed there failed to be documented evidence nursing interventions were developed related to assessing the patient's abdomen post surgical procedure.

Patient #5
Review of the medical record for patient #5 revealed the patient was admitted to the hospital on 8/29/16 with the diagnosis of recurrent seizures. Review of the medical record revealed a nursing care plan was not developed.

Patient #6
Review of the medical record for patient #6 revealed the patient was admitted to the hospital on 8/29/16 with the diagnosis of lower abdominal pain. Review of the nursing plan of care revealed there failed to be nursing interventions developed related to abdominal assessments.

Based on observation and interview, the hospital failed to ensure that the infection control officer developed a system for controlling infections of patients by failing to ensure that the hospital staff followed acceptable infection control standards of practice regarding patients requiring contact isolation precautions for 1 (Patient #7) of 1 patients identified by the hospital as requiring contact precautions in a total sample of 7.
Findings:

On 08/31/16 at 10:35 a.m., observation revealed S11RN/CN walked to the doorway of Patient #7, who was in contact isolation, and put on a gown and donned gloves. He was not observed to clean his hands prior to donning the gloves. At 10:40 a.m., S10RNP was observed to walk into patient #7's room and failed to don a gown and gloves. A few minutes later, S10RNP was observed to exit the patient's room and return to the nursing station. At that time, S10RNP was asked why patient #7 was on contact precautions and S10RNP replied she did not know the patient was on any precautions. She further stated that she did not see the isolation caddy or the signage on the patient's door.

On 08/31/16 at 1:25 p.m., observation revealed S12CNA walked to the doorway of Patient #7, who was in contact isolation, and put on a gown and donned gloves. S12CNA was not observed to clean her hands prior to donning the gloves. Further observations revealed she did not tie the gown, and it was hanging down off her shoulders.