HospitalInspections.org

Based on medical record review, interview and policy and procedure review, the facility failed to ensure that the nursing staff had current care plans for 3 out of 3 (#8, #9 and #10) discharged patients, which could result in the potential failure to achieve optimal patient outcomes.
Findings include:

On 4/10/13 at approximately 1330 during medical record review of patient #8 it was found that the care plan was not updated from 2/27/13 at 0700 to 2/28/13 at 2000.

On 4/10/13 at approximately 1400 during medical record review of patient #9 it was found that the care plan was not updated from 3/1/13 at 1130 to 3/3/13 at 0615.

On 4/10/13 at approximately 1430 during medical record review of patient #10 it was found that the care plan was not updated from 2/21/13 at 0600 to 2/24/13 at 0320.

On 4/10/13 at the time of the medical record reviews, staff F confirmed that the patients were lacking care plans for the dates and times stated.

On 4/10/13 at approximately 1430 during policy and procedure review, it was found in the policy titled, "Documentation: Nursing Process", which states under the section titled, "Evaluation", "The registered nurse will reference the outcome objective for the ND (nursing diagnosis) and CP care plan on the POC (plan of care) and document if the patient has achieved the outcome (including rationale of why and why not the outcome was achieved), once between 0700 and 1900, once between 1900 and 0700, as the patient's condition warrants, and when the patient is transferred to another level of care".