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DEER RIVER HEALTHCARE CENTER
No Description Available
Tag No.: C0298
Based on interview and document review, the facility failed to ensure care plans were developed for 4 of 9 patients (P1, P2, P4 and P7) reviewed for care planning.
Findings include:
On 11/8/2012 at 10:30 a.m., licensed practical nurse (LPN)-D was interviewed and stated the care planning process started within 24 hours of admission. She stated the care plans were pre-printed plans found in the kardex, reviewed and updated by the Registered Nurse (RN) or the LPN.On 11/8/2012 at 11:30 a.m. LPN-D was re-interviewed and stated there is a new process for care planning in the electronic medical record (EMR), however she was unaware of it and thought the care plans were still found in a kardex system.
On 11/8/2012 at 3:45 p.m., the EMR was reviewed with RN-C and revealed the following:
Patient (P)-1 was admitted on 11/6/2012 and did not have a developed care plan. RN-C stated P1 was planning discharge that afternoon and verified there was no care plan for P1 during the hospital stay. RN-C developed the care plan during our review.
P2 was admitted on 11/6/2012 and did not have a developed care plan in the EMR. RN-C stated P2 was planning discharge that afternoon and verified there was no care plan for P2 during the hospital stay. RN-C developed the care plan during our review.
P4 was admitted on 11/8/2012 at 12:30 a.m. At 3:50 p.m. on 11/8/2012, P4 did not have a care plan in the EMR. RN-C verified there was no care plan for P4 for over fifteen hours and completed the care plan during our review of the EMR.
P7 was admitted on 11/7/2012 at 11:00 p.m. and discharged on 11/8/2012 at approximately 8:30 a.m. P7 did not have a developed care plan in the EMR. RN-C verified P4 did not have a care plan developed during the hospital stay and completed it post discharge during our review of the EMR.
On 1/10/2013 at 11:45 a.m. the director of nursing (DON) stated the facility had switched to the EMR in May of 2012 and staff training was completed at that time. She stated all of the patients need a care plan and the care planning process had been identified as an area for improvement. The facility Care Planning Policy and Procedure dated 10/1/2003 directed staff to provide an individualized, interdisciplinary plan of care for all patients through the use of computerized care planning within 8 hours of admission.