HospitalInspections.org

Based on record review, staff interviews and hospital policy review the hospital is not meeting the Conditions of Participation for Nursing Services evidenced by A0392 - failure to ensure that patient needs are met by conducting initial and ongoing assessments of patients' needs and status, and at A0396 for failure to ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient.

1. The hospital failed meet the needs of patients as evidenced by incomplete or missing admission history forms for 18 of 20, Patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15, #16, #17, #19 and #20); incomplete or missing admission full assessments for 14 of 20, Patients (#1, #2, #5, #6, #7, #10, #11, #12, #14, #16, #17, #18, #19 and #20); incomplete or missing communication among caregivers for patient change in location 10 of 20, Patients (#1, #5, #6, #7, #8, #10, #11, #13, #17 and #18); incomplete ordered vital signs for 15 of 20, , Patients (# 1, #2, #3, #4, #5, #6, #7, #9, #10, #11, #13, #14, #16, #17 and #18); and incomplete or missing nursing order chart checks for 19 of 20 Patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, 12, #13, #14, #15, #16, #18, #19 and #20) each shift. (Refer to A0392).

2. The hospital failed to ensure that the nursing staff develops and keeps current, a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs for 13 of 20, Patients (# 1, #2, #3, #4, #5, #6, #9, #10, #11, #12, #13, #18 and #20) reviewed for care planning. (Refer to A0396).

Based on staff interviews, patient record reviews, and hospital policy reviews the hospital failed to ensure that patient needs are met by conducting initial and ongoing assessments of patients' needs and status. The records were incomplete or missing admission history forms for 18 of 20 patients, Patients' (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15, #16, #17, #19 and #20); incomplete or missing admission full assessments for 14 of 20 patients, Patients' (#1, #2, #5, #6, #7, #10, #11, #12, #14, #16, #17, #18, #19 and #20); incomplete or missing communication among caregivers for patient change in location for 10 of 20 patients, Patients' (#1, #5, #6, #7, #8, #10, #11, #13, #17 and #18); incomplete ordered vital signs for 15 of 20 patients, Patients' (# 1, #2, #3, #4, #5, #6, #7, #9, #10, #11, #13, #14, #16, #17 and #18); and incomplete or missing nursing order chart checks for 19 of 20 patients, Patients' (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, 12, #13, #14, #15, #16, #18, #19 and #20) each shift.

The findings included:

Review of hospital policy titled, "Provider Orders," revised 9/2019 stated, "Nursing and ancillary departments ensure that a patient's record is up to date and accurate. All patient care orders are to be reviewed every 24 hours by a nurse."

Review of hospital policy titled, "Assessment and Reassessment of Patient," revised 9/2019 stated, "The patient's status is assessed/reassessed continually throughout hospitalization ...The Registered Nurse (RN) will complete the initial assessment .... Inpatient Nursing (Telemetry) 1. Assessment will be performed within four (4) hours of patient's arrival on unit by RN. 2. Admission assessment database will be completed within 24 hours of admission and include the plan of care. Reassessments 1. Reassessments will be performed by the RN within 4-6 hours and/or when assuming responsibility for a patient's care..... 3. Cardiac rhythms will be assessed at least every shift, and more frequently if the patient has a change in their cardiac rhythm. A telemetry tracing of the cardiac rhythm will be posted in the chart every shift."

Review of hospital policy titled, "Communication Among Caregivers," revised 7/2019 stated, "2. Document transfer of care in patient's medical record when transfer occurs ....4. Hand-off communication is to take place at the bedside during the following: a. change of shift, b during transition/transfer of care between nursing units."

Review of hospital policy titled, Meaningful Use Clinical Documentation Policy," reviewed 10/2019 stated, "Clinical staff to capture family health history electronically."

Reviewed 20 clinical patient records for patient expected care including documentation of completed health history with twenty-four hours of admission, patient full head to toe assessment within 4 hours of admission to nursing inpatient unit, complete hand off communication documentation between nursing units, documentation of every shift chart checks for orders reviewed, cardiac telemetry rhythm strips documented every shift for patients on telemetry, and complete set of vital signs documented every four hours for inpatient care including temperature, heart rate respiratory rate, and blood pressure.

Eighteen of twenty records, Patients' #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15, #16, #17, #19 and #20 documented incomplete or missing health histories parts one and two which were to be completed within twenty-four hours of admission. Patients #1, #4, and #11 were missing health histories completely. Patient #2's health history was missing procedure history, past medical history, family history, and psychosocial/spiritual history. Patient #3's health history was missing procedure history, pain history review, past medical history, family history and psychosocial/spiritual history. Patient #5's health history was missing procedure history, pain history review, past medical history, family history and psychosocial/spiritual history. Patient #6's health history was missing procedure history, pain history review, past medical history, and family history. Patient #7's health history was missing procedure history, past medical history, family history and psychosocial/spiritual history. Patient #8's health history was missing procedure history, pain history review, past medical history, family history and psychosocial/spiritual history. Patient #9's health history was missing procedure history, pain history review, past medical history, family history and psychosocial/spiritual history. Patient #10's health history was missing procedure history, past medical history, family history and psychosocial/spiritual history. Patient #12's health history was missing procedure history, pain history review, family history and psychosocial/spiritual history. Patient #13's health history was missing pain history review, past medical history, family history and psychosocial/spiritual history. Patient #15's health history was missing past medical history, family history and psychosocial/spiritual history. Patient #16's health history was missing procedure history, past medical history, family history and psychosocial/spiritual history. Patient #17's health history was missing pain history review, past medical history, family history and psychosocial/spiritual history. Patient #19's health history was missing procedure history, pain history review, past medical history, family history and psychosocial/spiritual history. Patient #20's health history was missing procedure history, pain history review, and family history.

Fourteen of twenty records, Patients' #1, #2, #5, #6, #7, #10, #11, #12, #14, #16, #17, #18, #19 and #20, did not have a full head to toe assessment completed within four hours of admission to the inpatient unit. Patient #1 was admitted on 3/5/22 at 5:31 a.m., went to operating room and then arrived at inpatient unit on 3/15/22 at 2:40 p.m. First full assessment was completed 3/16/22 at 12:00 p.m. Patient #2 was admitted on 4/11/22 at 7:19 p.m., the first full assessment was completed on 4/12/22 at 1:00 p.m. Patient #5 was admitted on 5/8/22 at 10:28 a.m., the first full assessment was never completed. Patient #6 was admitted 5/6/22 at 12:53 p.m., the first full assessment was never completed. Patient #7 was admitted on 5/7/22 at 11:10 p.m., first full assessment was completed 5/8/22 at 8:00 p.m. Patient #10 was admitted on 5/8/22 at 3:04 p.m. first full assessment completed 5/8/22/at 11:38 p.m. Patient #11 was admitted on 4/24/22 at 1:11 p.m., never had a full assessment completed. Patient #12 was admitted on 4/24/22 at 5:20 p.m., never had full assessment completed. Patient #14 was admitted 4/30/22 at 9:58 a.m., never had full assessment completed. Patient #16 was admitted 4/30/22 at 8:18 p.m., full assessment completed 5/1/22 at 12:00 p.m. Patient #17 was admitted on 5/8/22 at 10:26 p.m. never had a full assessment completed. Patient #18 admitted on 5/5/22 at 9:37 p.m., full assessment completed 5/7/22 at 4:00 a.m. Patient #19 was admitted 4/28/22 at 10:48 p.m., full assessment completed 4/29/22 at 1:00 p.m. Patient #20 admitted 5/6/22 at 10:53 p.m. full assessment completed 5/7/22 at 2:00 p.m.

Ten of twenty records, Patients #1, #5, #6, #7, #8, #10, #11, #13, #17 and #18, did not have complete documentation of handoff report and disposition of patient when moved to inpatient unit. Hand off communication is needed to maintain continuity of patient care. Hand off documentation includes who is receiving report on patient status, how the patient is transported to admitting unit, who transports the patient to the admitting unit and what equipment, if any, is being used for patient while in transport including telemetry monitoring, and oxygen. Patients #1, #5, #6, #7, #8, #10, and #18 had no documented hand off from the emergency room in clinical record. Patient # 11's documentation missing a name for who was given report/hand off. Patient #13 documentation was missing who conducted transport and what equipment was used during transport. Patient #17's documentation was missing who was given report/hand off, who conducted transport and what equipment was used during transport.

Eighteen of twenty records reviewed, Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15, #16, #18, #19 and #20, did not have documentation of chart checks completed by nurses to ensure patient orders were reviewed and implemented every shift per hospital policy and staff education. Patients #1, #2, #4 and #6 did not have any chart checks documented in clinical records. Patient #3 had 2 of 4 expected chart checks completed. Patient #5 had 1 of 5 expected chart checks completed. Patient #7 had 5 of 10 expected chart checks completed. Patient #8 had 7 of 12 expected chart checks completed. Patient #8 had 7 of 12 expected chart checks completed. Patient #9 had 7 of 12 expected chart checks completed. Patient #10 had 3 of 8 expected chart checks completed. Patient #11 had 4 of 9 expected chart checks completed. Patient #12 had 10 of 21 expected chart checks completed. Patient #13 had 5 of 9 expected chart checks completed. Patient #15 had 9 of 13 expected chart checks completed. Patient #16 had 6 of 21 expected chart checks completed. Patient #18 had 8 of 14 expected chart checks completed. Patient #19 had 18 of 28 expected chart checks completed. Patient #20 had 6 of 12 expected chart checks completed.

Two of twenty records, Patients #3 and #12, were missing telemetry strips for the timeframe they were on telemetry at hospital. The hospital was unable to provide evidence that the patients had cardiac rhythms monitored each shift for these two patients.

Eleven of twenty records, Patients # 1, #2, #4, #5, #6, #7, #9, #10, #11, #13, and #16, documented missing portions of vital signs monitoring which were to include patient temperature, heart rate, respiratory rate, and blood pressure every four hours per policy. Patient #1 was in the hospital 3/15/22 at 5:31 a.m. to 3/17/22 at 12:30 p.m. Documentation for Patient #1 showed 11 of 13 vital signs opportunities completed. Patient #2 in was in the hospital 4/11/22 at 7:19 p.m. to 4/12/22 at 11:45 a.m. Documentation for Patient #2 showed 5 of 7 vital signs opportunities completed. Patient #4 was in the hospital 4/25/22 at 10:20 a.m. to 4/26/22 at 8:05 a.m. Documentation showed 2 of 6 vital signs expected opportunities completed. Patient #5 was in the hospital 5/8/22 at 10:28 a.m. to 5/10/22 4:25 p.m. Documentation showed 5 of 13 vital signs opportunities completed. Patient #6 was in the hospital 5/6/22 at 12:53 p.m. to 5/10/22 at 9:25 a.m. Documentation showed 16 of 23 vital signs expected opportunities completed. Patient #7 was in the hospital 5/7/22 at 11:10 p.m. to 5/10/22 at 11:00 a.m. Documentation showed 8 of 15 vital signs opportunities completed as expected. Patient #9 was in the hospital 5/4/22 at 11:10 p.m. to 5/7/22 at 11:00 a.m. Documentation showed 12 of 15 vital signs opportunities completed as expected. Patient #10 was in the hospital 5/8/22 at 3:04 p.m. to 5/12/22 at 12:00pm. Documentation showed 18 of 23 vital signs opportunities completed as expected. Patient #11 in hospital 4/24/22 at 1:11 p.m. to 4/27/22 at 8:42 a.m. Documentation showed 9 of 17 vital signs opportunities completed as expected. Patient #13 in hospital 5/1/22 at 11:15 p.m. to 5/6/22 at 10:13 a.m. Documentation showed 20 of 26 vital signs opportunities completed as expected. Patient #16 in hospital 4/30/22 at 8:18 p.m. to 5/11/22 at 12:52 p.m. Documentation showed 35 of 64 vital signs opportunities completed as expected.

On 5/10/22 at 3:15 p.m., during patient electronic records review with clinical informatics RN/Educator and Risk Manager, the Risk Manager and Clinical Informatics RN confirmed all patients were to have a full "head to toe" assessment completed and documented in the records within four hours of admission to the inpatient unit. Clinical Informatics RN and Risk Manager confirmed that the patient health history was to be completed within twenty-four hours of admission. Asked Clinical Informatics RN why the health history was marked as completed when the individual parts to the form were not filled in. Clinical Informatics RN confirmed that the form will document 'completed' if any question is answered on the page even if only one and the rest left blank. When asked if they viewed this as a completed a health history, the Risk Manger replied, "No, that is not complete, and it is not individualized. You can tell they are just trying to get the check mark for the task."

On 5/11/22 at 2:00 p.m., interviewed Risk Manager about recent education for chart checks and reviews. The Risk Manager stated, "The nurses are expected to do a chart check every 12 hours." Risk Manager confirmed the staff had recent education in March 2022 and April 2022 about this expectation. Risk Manager confirmed it is not being done consistently and replied, "It is a risk for patient safety. We have been doing audits, but I see there are opportunities for education for the managers doing the audits." Risk manager confirmed portions of vital signs were missing, care plans were not being individualized, and full assessments on admission were not being completed within the four hours as expected.

On 5/11/22 at 2:25 p.m., during a meeting with the Chief Nursing Officer (CNO). Chief Executive Officer (CEO), Executive Director of Nursing, Chief Quality Officer (CQO), Risk Manager and clinical informatics RN, the CNO said the expectation for patient care planning is they should be individualized. When given example of Patient #10 with abdominal distention and who had gone to OR but was only care planned for falls, urinary catheter, and discharge planning, the CNO replied, "that is not acceptable". The CNO confirmed that complete head to toe assessments are to be completed within four hours of admission for inpatient care. The CNO confirmed vital signs every four hours included temperature, heart rate, respiratory rate, blood pressure and if on oximetry then oxygen saturation. The CNO confirmed the expectation for complete hand off when transferring a patient from the emergency room included report and who did the transport. The CNO confirmed the expectation that nurses complete a chart check each twelve-hour shift for order review. The CNO confirmed the Health History parts 1 and 2 form is to be completed by nursing staff within 24 hours of admission.

Based on patient records review, hospital policy review, and staff interviews the hospital failed to ensure that the nursing staff develops and keeps current, a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs for thirteen patients, Patients' # 1, #2, #3, #4, #5, #6, #9, #10, #11, #12, #13, #18 and #20 of twenty patients reviewed for care planning .

A nursing care plan is based on assessing the patient's nursing care needs (not solely those needs related to the admitting diagnosis). The assessment considers the patient's treatment goals and, as appropriate, physiological, psychosocial factors, and patient discharge planning. The plan develops appropriate nursing interventions in response to the identified nursing care needs. The nursing care plan is kept current by ongoing assessments of the patient's needs and of the patient's response to interventions and patient treatment goals. The care plan is updated and revised in response to assessments.

The finding included:

Review of hospital policy titled, "Interdisciplinary Plan of Care," revised 4/1/2019 stated, "The Nursing Team, in conjunction with the patient and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each patient. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.... The nurse completing the patient admission database is responsible for initiating the Interdisciplinary Plan of Care (IPOC).... The IPOC documentation will be updated/reviewed at a minimum of every 24 hours as either met or not met; done or not done; or progressing by nursing related to their actions completed or not completed throughout the shift.... is updated as the patient's care needs change as evidenced by the progress toward established goals."

Review of hospital policy titled, "Care Planning Documentation System," reviewed 10/2019 stated, "Each caregiver is responsible for accurate documentation of care provided."

Clinical records reviewed for care planning found no care plan present for 9 of 20 records reviewed, Patients' #1, #2, #3, #4, #5, #9, #11, #12, and #13. For Patient #6, the care plan was not individualized based on patient needs or admitting diagnosis. Patient #6 was admitted for abdominal pain and weight loss. Patient #6's care plan was for ineffective airway clearance and discharge planning. Patient #10 was admitted for abdominal pain and the care plan was for falls, urinary catheter and discharge planning. Patient #18 was admitted for sepsis alert was care planned for self-care deficit, bathing, falls, and discharge planning. Patient #20 was admitted for altered mental status was care planned for imbalanced body temperature, risk for pressure ulcer, discharge planning, and risk for falls.

On 5/10/22 at 3:15 p.m., patient electronic records reviewed with clinical informatics RN/Educator and Risk Manager. Clinical informatics RN and Risk manager confirmed that many of the records did not have IPOCs initiated for the patient being reviewed. The Risk Manager said: "The nurses are supposed to review and update each shift. These should be done but they are not."

On 5/11/22 at 8:45 a.m., while continuing chart reviews with Clinical Informatics RN and Risk Manager, the Clinical Informatics RN said the care plans are not getting initiated, and the nurses are not individualizing them. She said, "We went live with Cerner in September 2021, and they were educated on how to complete care planning for patients."

On 5/11/22 at 2:25 p.m., during a meeting with the Chief Nursing Officer (CNO), Chief Executive Officer (CEO), Executive Director of Nursing, Chief Quality Officer (CQO), Risk Manager and Clinical Informatics RN, the surveyor presented an example of Patient #10 admitted with abdominal distention and who had gone to OR but was only care planned for falls, urinary catheter, and discharge planning. The CNO said they should be individualized and stated, "That is not acceptable".