HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current, an individualized 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. This deficient practice is evidenced by the failure to update the nursing care plans on 3 (#1, #2, #3) of 3 (#1-#3) sampled patients reviewed for completed and updated nursing care plans.
Findings:

A review of facility policy number PE-150 titled, "Patient Care, Planning of" revealed in part, under the section Policy 1. The interdisciplinary caregivers work collaboratively to assess patient needs and to develop an individualized plan of care which is implemented, evaluated, revised, and terminated throughout the patient's hospital stay. The plan of care integrates the information from various assessments of the patient, to identify and assign priorities to the patient's needs. 5. The Interdisciplinary Plan of Care is reviewed and updated in the electronic medical record every 24 hours by the Registered Nurse (RN) and is based upon assessment needs/resolution.

A medical record review on 02/20/2024 at 2:53 p.m. revealed Patient #2 was a moderate to high risk for falls during nursing assessments completed during hospitalizations dated 12/11/2023 and 01/03/204 by RNs. There was no documentation indicating Patient #2's nursing care plans had initiated or been updated to include this medical diagnosis or treatment interventions.

In an interview on 02/20/2024 at 3:00 p.m. S1DR and SI3nformatics confirmed there had been no initiation of fall risk or updates to Patient #2's nursing care plan.

A medical record review on 02/20/2024 at 3:15 p.m. revealed Patient #1's care plan had not been reviewed or updated on 12/14/2023 and 12/15/2023 by the RN. There was no documentation indicating patient #1's nursing care plan had been reviewed or updated.

In an interview on 02/20/2024 at 3:35 p.m. S1DR and S3Informatics confirmed there had been no updates made by the RN to Patient #1's nursing care plan.

A medical record review on 02/20/2024 at 3:55 p.m. revealed Patient #3's care plan had not been reviewed or updated on 01/05/2024 and 01/06/2024 by the RN. There was no documentation indicating patient #3's nursing care plan had been reviewed or updated.

In an interview on 02/20/2023 at 4:15 p.m. S1DR and S3Informatics confirmed there had been no updates made by the RN to Patient #3's nursing care plan.