HospitalInspections.org

Based on hospital failed to keep current a nursing care plan for each patient that reflects nursing care to be provided to meet the patients needs in that, 1 of 1 (patient#1) patient was diagnosed with Asthma and required treatment for the asthma. The nursing care plan did not evidence asthma as a diagnosis.

Findings included:

Patient #1 was admitted on 05/25/23 for aggression. The Medical Consultation form dated 05/28/23 reflected..."Hx (history) Asthma-use inhaler...Pro Air..."
The Physician Orders dated 05/28/23 at 1245 reflected..."Pro Air HFA...2 puffs q4 hrs PRN for SOB (every four hours as needed for shortness of breath)..."
The medical record did not evidence a nursing care plan for asthma.

During an interview with Personnel #2 on 06/07/23 at 1340 Personnel #2 acknowledged there was not a care plan plan update for asthma on the chart.