HospitalInspections.org

Based on interview and record review, the facility failed to establish an individualized plan of care for 2 (P-3, P-4) of 11 patients reviewed, resulting in the potential for negative outcomes for these patients. Findings include:

P-3: This 83-year-old female with a past medical history of hypertension, hyperlipidemia, diabetes, and cardiac artery disease with bypass presented to the emergency department on 4/13/25 with symptoms of shortness of breath and wheezing. During record review on 4/16/25, it was noted that the record failed to include a plan of care.

P-4: This 77-year-old male with a past medical history of normal pressure hydrocephalus, stroke, moderate dementia, hypertension, overactive bladder, chronic back pain, and gastroesophageal reflux disease presented to the emergency department on 4/10/25 with new onset seizures. During record review on 4/16/25, it was noted that the nursing plan of care included fall prevention. There was no evidence the plan of care addressed new onset of seizures or any other chronic conditions, such as pain.

These findings were reviewed and acknowledged by the 5 West Nurse Manager (Staff-K) at time of discovery.

Policy 17214604 - Guidelines of Practice for Patient Care (Revised 1/3/2025). The Plan of Care (POC) shall be initiated for all patients within 24 hours of admission. The RN is responsible for determining the patient's health care needs and initiating identified Multidisciplinary Care Plans (MCP's) with anticipated goals. The MCP goals shall be reviewed and updated at least every 24 hours, and when the patient's condition and/or Plan of Care changes.