HospitalInspections.org

Based on interview and review of medical records, it was determined that the hospital did not develop and keep current nursing care plans for patients. The hospital's failure to do so resulted in 6 of 6 patients whose medical records were reviewed, not having nursing care plans.

Findings include:

Five (5) medical records were selected from a list of patients who were admitted to the hospital through the Emergency Department during the same approximate period of time as Patient #1, the patient identified in the complaint.

Each medical record was reviewed for evidence of a nursing care plan, by the investigator and by a hospital staff nurse. All medical records had an "integrated" plan of care; however, none of the medical records had a nursing care plan, specifically developed by Registered Nurses, to address the nursing care needs of each patient.

Review of the Registered Nurse position description revealed the following directions under NURSING PROCESS.

"C. Nursing Plan of Care
1. Using the admission database, develops with the patient, Care Teeam, physician, and appropriate ancillary staff and [sic] ongoing plan of nursing care with realistic, measurable goals..."


Review of the hospital's "INPATIENT PROCEDURE, Clinical Documentation", revealed the following:

"A Plan of Care:
...The Nursing plan of care consists of problems, interventions and outcoms identified. The nursing staff develops and keeps current the Nursing plan of care for each patient..."

In addition, review of the hospital's "Restraints(s)" policy and procedure revealed no evidence that the nurse was to make a written modification to the patient's plan of care while the patient was in restraints. The policy had multiple instances in which the RN was to make determinations about patient care "...in collaboration with the multidisciplinary team".

Interview with the Chief Nursing Officer (CNO) revealed that the hospital did not have a policy and procedure regarding the development and implementation of nursing care plans. The CNO also acknowledged that not all determinations about patient care, for example the utilization of restraints, would include the "multidisciplinary team", and such determinations would be appropriately made by credentialed medical staff and Registered Nurses.

Although multiple hospital documents referenced nursing care plans, the actual practice of the hospital was to utilize a "multidisciplinary" care plan which did not specifically identify the nursing process. The hospital's failure to develop and implement a policy for nursing care plans placed all patients in the hospital at risk for unidentified and unmet nursing care needs.