HospitalInspections.org

Based on record review and interview the facility failed to ensure that nursing care plans were kept current in two (#2, # 7) of ten patients charts reviewed

Findings Include:
Facility policy Care Planning dated -1/2019, the policy stated:

Assess each patient at the time of admission and continuously
throughout the patient's hospitalization as warranted by changes in the
patient's care needs through systematic collection of data in the
following areas: biophysical, psychosocial, risk/environmental,
educational, and discharge planning.

Record review, and interview on 11/22/2022 at 1031 revealed patient (ID#3) was admitted on 09/06/2022 with a diagnosis of autism. The care plan had no updates in the record from admission 09/06/2022 to current (11/22/2022).

Interview with the staff (ID#55) who noted her care plan had not been updated since admission and should have. "We update them every week".

Record review and interview of patient (ID#7) who was admitted on 06/04/2022, she was a diabetic and had not been addressed on the care plan.

Interview with staff (ID#55) who stated she did not see it, and it should have been addressed, and updated weekly.