HospitalInspections.org

Based on interview and record review the facility failed to ensure nursing care plans were kept current by ongoing assessments of the patient's needs and of the patient's response to interventions, and updating or revising the patient's nursing care plan in response to assessments in one of eleven sampled nursing care plans. (ID#1)

Findings include:

Record review of one of eleven patient care plans (Patient ID#1) did not address the patient's problem with constipation.

Record review of the care plan for patient (ID #1) dated 4/25/2017 revealed no problems associated with constipation. The patient was discharged on May 12th, 2017.

Record review of a physician order dated 4/25/2017 at 10:30 a.m. stated "Docusate Sodium 100mg" (Colace, stool softer).

Record review of physician process dated 4/26/3017 at 0700 states patient has a past medical history of constipation.


Interview with RN, (staff #55) on May 31, 2017 at 1041 stated "additional problems and associated outcomes can and should be documented every shift. The care plan should be modified".

Interview with RN (staff #52) on May 31, 2017 at 1046 stated "something should have been added (to the care plan) on April 28, 2017 when the first Dulcolax (suppository) was given for constipation".

Record review of hospital facility policy titled Treatment Planning Process, dated 6/2015 stated "The interdisciplinary Treatment Plan is initiated by the Admitting Nurse on admission...Medical, psychiatric and educational needs are assessed.
L. Individual Treatment Plans are written based on the active problem identified".

Based on interview and record review it was noted that nurses did not chart necessary information in the medical record to monitor the patient's condition. Review of patient (#1) did not have nurses notes in the medical record to validate the physician was notified about the redness and a tear noted on peri area.

Findings include:

Record review of physician's orders dated May 6, 2017 at 0500 written as a telephone order from the physician (staff # 67) by RN (staff #59) revealed an order was obtained for Sween cream to be applied to the affected area four times per day and when ever necessary.

Interview with RN (ID #68) on May 15, 2017 at 0715 stated "On May 5, 2017 I was called to room 232-W to patient (ID #1) room. Incontinent care was being done. The charge nurse (ID #69) and I (ID #68) noted patient to have redness and a tear around the rectal area. We passed this information on to the day shift May 6, 2017". The physician was not notified of a rectal tear.

Record review of nursing notes on May 6, 2017 at 0548 by RN (ID #59) noted Sween cream applied to reddened area.

Record review of nursing notes and nursing care plan from May 7, 2017- May 12, 2017, have no mention of redness or tear noted around rectal area.