HospitalInspections.org

Based on policy and procedure review, medical record review, and personnel interview, nursing staff failed to supervise and evaluate the nursing care for each patient related to lack of initiation or updating of a plan of care and lack of following physician's orders for manual disimpaction bowel program for 1 of 5 (N1) closed patient medical records reviewed.

Findings:

1. Policy No.: ASSESS-011 titled "Patient Care Plans/Pathways", revised/reapproved 4/2012, was reviewed on 5/15/14 at approximately 4:22 PM, indicated under:
A. General Information section, "Care Plans/Clinical Pathways are to be initiated on admission and reviewed/revised daily and PRN (as needed) to reflect significant changes in the patient's status."
B. Admitting New Patients section, "When admitting a patient the RN (Registered Nurse) shall: 1.A. Pathway - use a pre printed clinical pathway as appropriate for the patient diagnosis and individualize for the patient. Date, time and sign the pathway. 1. B. Care Plan - Initiate the electronic Patient Care Plan Power form. Complete the mandatory education section and the appropriate sections to reflect the patient's diagnosis/needs. Sign the form. 2. Client centered outcomes that are reasonable and measurable are to be provided for each patient on their care plan/clinical pathway."

2. Review of closed patient medical records on 5/15/14 at approximately 1:00 PM, indicated Patient:
A. N1 was a 68-year-old who was admitted to the 3rd Floor Med-Surg Telemetry Unit on 3/2/14 for further medical management:
a. per ED Notes dated 3/2/14 at 1310 PM, "Spoke to patient's [family] by phone, confirms desire for admission. Wants to remind us to order fecal disimpaction."
c. per Physician's Orders dated:
i. 3/2/14 at 1723, initiate plan of care.
ii. 3/4/14 at 1659, "Tuesdays and Fridays, patient is to be digitally disimpacted."
d. Plan of Care dated 5/2/14 through 5/7/14 lacked documentation of initiation or updating of a plan of care related to bowel program for manual disimpaction.
e. Nurses Notes lacked documentation of manual disimpaction on Tuesday 3/4/14 and Friday 3/7/14.

3. Personnel P1, RN, was interviewed on 5/15/14 at approximately 3:06 PM via phone and confirmed failed to update the plan of care for patient N1 on 3/4/14.

4. Personnel P7, Director of Quality, was interviewed on 5/15/14 at approximately 4:40 PM and confirmed, patient's plan of care lacked daily documentation of initiation or updating of a plan of care related to bowel program for manual disimpaction by nursing staff 5/2/14 through 5/7/14 and is a nursing standard, as well as required by facility policy and procedure. Physician's Orders for digital disimpaction on Tuesdays and Fridays was also not followed.