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Based on reviews of medical records, observations of computerized care plan, policies and procedures and interview was determined the facility failed to maintain a current nursing plan related to the patient's admission diagnosis. The facility also failed to follow their care plan policy and procedure for 1 (#15) of 24 sampled patients.

Findings:

The facility's policy titled "Clinical Documentation-inpatient, policy # COP #187, approved June 2011 was reviewed. The section of the policy titled " B. Plan of Care" revealed in part, " 1. Plan of care should be completed within 8 hours of admission. Clinicians will add parameters related to the admitting diagnosis that is most appropriate to the patient ....4. Chronic problems will be included in the plan of care only if they are uncontrolled and/or impact the care. "

Review of the medical record for Patient #15 revealed that the patient arrived to the hospital's emergency department on 1/11/2017 at 12:08 PM, via ambulance. The ED (emergency department) triage nurse's note revealed that the patient's the chief complaint was substance abuse. The note further revealed that the 'patient is here for help with detoxification from alcohol.' The reason for admission was 'EMS ALCOHOL WITHDRAWALS'. The ED nurse triaged the patient as ESI (Emergency Severity Index-emergency triage based upon the acuity of patients health care problems and the number of resources their care is anticipated to require) 2 (Level 2- high risk situation, confused/lethargic/disoriented, sever pain distress, abnormal vital signs). The patient's vital signs were as follows:-

· Blood Pressure: 151/86;
· Pulse 102 (norm 60-100);
· Respiratory Rate: 20;
· Oxygen saturation was 96%;
· Temperature: 99.3.

Review of the Psych Initial Assessment sheet dated 1/11/2017 revealed that the patient's disposition as 'Inpatient' and the rationale for level of care sought was "ETOH (Alcohol) WITHDRAWAL." History of Present illness revealed that the patient came to the ED requesting ETOH detoxification. The patient presented with a heart rate of 102, tremor, nausea, and anxiety. The patient reported that he/she needed help to stop drinking, suffered from decreased sleep and loss of appetite and that he/she had been using ETOH to self-medicate. The patient denied suicidal or homicidal ideations and self-harming. Current psychiatric impairments revealed that the patient was wearing disheveled street clothes. The patient presented with agitation and mumbled speech. The patient was cooperative, exhibiting normal thought content and normal memory. During review of Patient #15's computerized care plan with the Registered Nurse and the Director of the Psychiatric Unit, it was observed that patient #15 was not care-planned for her current diagnosis of ETOH withdrawal. There was also no care plan for patient #15 in the paper chart relating to ETOH withdrawal.

An interview was conducted with the Director of the Behavioral Health Unit on 1/12/2017 at 11:00 a.m. The Director of the Behavioral Health Unit stated that Patient #15 should have been care planned for his/her ETOH Withdrawal/dependence diagnosis. There were no documented parameters on the care plan related to the patient admitting diagnosis of ETOH withdrawal as stated in the hospital's policy and procedure.