HospitalInspections.org

The facility must ensure that the nursing staff develops and keeps current, a nursing care plan for each patient that reflects the patients' needs. The nursing plan may be part of an interdisciplinary care plan.

Based on interview and record review on 10/09/2018 doing observation between 1000 - 1230, the facility failed to ensure nursing care plans were kept current by ongoing assessments of the patients' needs and the patient's response to those interventions in 10 of 15 patients (Patient ID #1, 3, 4, 5, 6, 7, 8, 11, 12, 19)

Findings:

Record review of the current hospital policy titled "Interdisciplinary Plan of Care" dated 5/07 stated:

The patients plan of care must address the reason for hospitalization of the patient; the patients' chief complaint; and the patient's medical and nursing diagnoses."
Should be initiated within twenty-four (24) within admission

Findings include:

Record review of history and physical and plan of care of random patient records reviewed on 10/09/2018, from units 3A and 3C, revealed:

Patient (ID# 1), a 52-year old male was admitted for hypertension., hepatitis C virus, intravenous, drug use and left leg cellulitis
The care plan did not address the patients' hypertension.

Patient (ID# 3), a 56-year-old female admitted on 10/8/2018 for congestive heart failure, exacerbation, essential hypertension and paroxysmal atrial fibrillation
Record review of the plan of care did not address congestive heart failure.

Patient (ID# 4), a 38-year-old female, was admitted 10/08/2018 for abdominal pain, with a diagnosis of cholecystitis, was admitted for surgery.
The care plan did not reveal the nutritional status related to the patients' surgery.

Patient (ID# 5), a 55-year-old male, was admitted on 10/07/2018 for intra-abdominal abscess, and was admitted for surgery.
The care plan did not reveal did not address surgery or the complications related to.

Patient (ID# 6), a 59-year-old male, admitted for essential hypertension, Hepatitis C, chest pain, acute left knee, bursitis and septic cellulitis after a spider bite, and is a pre-diabetic.
The care plan did not address the patient's pre-diabetes.

Patient (ID# 7), a 54 year female, was admitted for right femoral neck fracture, hypertension, diabetes mellitus, Hyperlipidemia, and previous Cerebrovascular accident.
The care plan but did address hypertension or nutrition.

Patient (ID# 8), a 56-year-old male, admitted 10/7/2018 with a left arm wound with growing strep anginosus, with Necrotizing soft tissue infection, and required an incision and drainage of the wound. He also received Humlin insulin every 6 hours.
Care plan did not address the patient's mobility or diabetes.

Patient (ID #11), a 28-year-old male admitted on 08/28/2018 with a diagnosis pre-septal cellulitis, large necrotic wounds bilaterally on the lower extremities, bacterial osteomyelitis and depression
Care plan did not address the patients' depression.

Patient (ID# 12), a 50-year-old male admitted on 09/30/2018 for metastatic prostate cancer, with hypertension and diabetes.
The care plan did not address either the hypertension or the diabetes

Patient (ID# 19), 32-year-old male admitted 10/7/2018 with hypertension and end stage renal disease.
The care plan did not address hypertension.

Interview with Nurse Manager (staff ID #73) on 10/09/2018 at 1130 stated the care plans should reflect the patients care and updated as needed.