HospitalInspections.org

Based on staff interviews and medical record review the facility failed to ensure that patient's care needs for 1 of 25 patients reviewed (patient #14), were assessed and reassessed to evaluate known medical conditions and that a established Treatment Plan of Care was implemented.
Findings:
Review of the medical record for patient # 14 revealed that the patient had admitting diagnosis to include diagnosis of Asthma, hypertension, Gastroesophageal Reflux Disease (GERD), Chronic Obstructive Pulmonary Disease ( COPD ) and chronic pain. Review of the admission physician orders dated on 03/10/2012 at 5:05 PM included Albuteral inhaler 90 mcq inhaler two times a day at 0800 and 5:00. No care plan was initiated for this patient.
Review of history and physical for patient # 14 written on 03/10/2012 by the medical doctor revealed under Assessment that patient has a history of Asthma and Chronic obstructive Pulmonary Disease and does show that patient # 14 takes Albuteral inhaler at home.
Review of nursing notes each shift does include that patient # 14 is complying with taking medications twice a day as ordered from 03/10/2012 to 03/14/2012.
Review of the medical record for patient # 14 reveal that pulse oximetery was not performed on the patient to ensure the patient remained within safe levels of blood oxygen saturation. In reviewing initial care plan and assessment on 03/10/2012 reveals that master medical problem list numbered 6 that was for COPD and Asthma showed a status of D.
Interview with Licensed Practical Nurse ( LPN ) on 03/14/2012 at 9:50 AM states that D in the status column means it is deferred and no care plan for ineffective breathing was initiated. States that she does not know why it was deferred or that oxygen saturations are not being done each shift.
Interview with Registered Nurse who is the Unit Manager on day shift on 03/14/2012 at 10:05 AM who also does not know why the condition was deferred and not care planned, but also states that other nurses should have initiated the ineffective breathing care plan. All nurses were in-serviced on documenting care plan for ineffective breathing.
Interview with Admissions Registered Nurse/Supervisor on 03/14/2012 at 10:25 AM revealed that did not know why this particular patient had the problem deferred because the patient is on the medication twice a day. If the patient had history but not on medication, then it would be deferred.

Based on interviews and record review for 1 of 25 patients reviewed (patient #14), the facility to failed ensure that patient's care needs were assessed and reassessed to evaluated known medical conditions and to develop and keep current a Treatment plan of Care.

Findings:

Review of the medical record for patient # 14 revealed that the patient had admitting diagnosis to include diagnosis of Asthma, hypertension, Gastroesophageal Reflux Disease (GERD), Chronic Obstructive Pulmonary Disease (COPD) and chronic pain. Review of the admission physician orders dated 03/10/2012 at 1705 (5:05 PM) included Albuteral inhaler 90 mcq inhaler two times a day at 0800 (8:00 AM) and 1700 (5:00 PM). Further review of this patient's record revealed that no care plan was initiated for this patient.

Review of history and physical for patient #14, that had been reviewed on 03/10/2012 by the medical doctor revealed under Assessment that patient has a history of Asthma and Chronic Obstructive Pulmonary Disease and does show that patient #14 takes Albuteral inhaler at home.

Review of nursing notes for each shift does include that patient #14 is complying with taking medications twice a day as ordered, from 03/10/2012 to 03/14/2012. The nurses notes do not reveal that the nursing staff reassessed the patients oxygen saturation during admission in the facility.

Review of the medical record for patient #14 reveal that pulse oximetery was not performed on the patient to insure the patient remained within safe levels of blood oxygen saturation. In reviewing the initial care plan and assessment that was completed on 03/10/2012 reveals that master medical problem list numbered 6 was for COPD and Asthma and it showed a status of D.

Interview with Licensed Practical Nurse (LPN) on 03/14/2012 at 9:50 AM states that D in the status column means it is deferred and no care plan for ineffective breathing was initiated. Further interview revealed that she does not know why it was deferred or why oxygen saturations are not being done each shift.