HospitalInspections.org

Based on medical record, policy and procedure review and staff interview the facility failed to provide comprehensive plans of care for 6 (Patients #6, 7, 9, 10, 13, and 14) patients of a sample of 14 patients reviewed for comprehensive plans of care. The facility census was 119.

Findings included:





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Patient #6 was admitted to the facility on 05/02/13 with diagnoses which included major depression, Parkinson's disease and history of a pressure sore to the coccyx prior to her admission at the facility. Review of the facility Skin and Restraint Prevalence Rounds sheets documented the patient had a stage II pressure sore to her coccyx area. Review of the patient's plan of care failed to document a care plan for skin care for Patient #6. These findings were verified with Staff E on 05/07/13 at 2:21 P.M.

Patient #7 was admitted to the facility on 05/01/13 with diagnoses which included advanced depressive disorder, diabetes mellitus, hypertension, and thyroid disease. Review of the medical record revealed the patient was admitted to the facility with a history of a Stage II sacral pressure ulcer. Review of the patient's plan of care failed to reveal a care plan for skin care for Patient #7. These findings were verified with Staff E on 05/07/13 at 2:30 P.M.

Patient #9 was admitted 05/01/13 with diagnoses of paranoia schizophrenia, frontal temporal dementia and history of a surgically repaired pressure ulcer present on admission to the facility. Review of the patient's plan of care failed to document a care plan for skin care Patient #7. These findings were verified with Staff E on 05/07/13 at 2:42 P.M.

Patient #10 was admitted to the facility on 05/06/13 with diagnoses which included major depressive disorder, hypertension, chronic pain low back pain for the past three months with the use of routine analgesic medications. Review of the patient's plan of care failed to document a skin plan of care for Patient #7. These findings were verified with Staff A on 05/07/13 at 2:42 P.M.

Patient # 13 was admitted to the facility on 05/02/13 with diagnoses of abdominal distention, presence of a coccygeal pressure ulcer present prior to admission and assessed at risk via the Braden Scale Assessment tool for pressure sores and was receiving wound treatments by facility staff. Review of the patient's plan of care revealed the facility had failed to initiate a skin plan of care until 05/07/13.
These findings were verified with Staff F on 05/07/13 at 9:40 A.M.


Review of the facility's policy and procedure entitled Nursing Plan of Care with an approval date of 01/11/2011 directed nurses that a plan of care is a individualized based on patient needs. Item 5 on the content of a plan of care directed that each patient's problem is selected in the Plan of Care Flowsheet and are to be updated every 24 hours, or when changes occur or problems are resolved.

Interview with Staff A on 05/07/13 at 10:03 A.M. verified the patient plans of care were not comprehensive and failed to address patient care needs.

The clinical record review for Patient #14 was completed on 05/08/13. The record review revealed the 58 year old patient was admitted to the facility on 04/28/13 with a chief complaint of shortness of breath. The clinical record review revealed the patient had abdominal surgery on 05/04/14. On 05/03/13 at 3:25 A.M. the patient had abdominal pain 8 out of 10 (ten being the highest), at 7:35 A.M., and 8:00 A.M. The patient had pain rated as 10 out of 10 on 05/04/13 at 12:01 A.M. On 05/04/13 at 6:53 P.M. the patient was taken to the operating room. The record review revealed an operative report dated 05/04/13 that stated the patient had a perforated portion of the bowel. The clinical record review did not reveal a care plan for pain.

The clinical record review for Patient #14 revealed (post operatively) on 05/04/13 the patient was bedbound and at high risk for a pressure sore. The clinical record review revealed on 05/05/13 and 05/06/13 the patient was bedbound and at high risk for a pressure sore. The clinical record review did not reveal a care plan for skin care until 05/06/13. On 05/08/13 at 11:30 A.M. Staff B and D confirmed the finding.