HospitalInspections.org

Based on observation, interview, record review and policy review, the facility failed to ensure that patients' nursing care plans were developed and kept current for two patients (#6, #18) of 11 patients whose medical records were reviewed for nursing care plan goals and interventions. This had the potential to affect all patients by failing to ensure that the patients' physical and psychological needs were met. The facility census was 94.

Findings included:

1. Record review of the facility's policy titled, "Treatment Planning and Documentation," revised 01/16/14, showed that the treatment planning process included the identification of problems and goals, and relevant interventions as determined by on-going assessments of patients' needs.

2. Record review of Patient #6's medical record showed the following:
- Admission orders dated 10/06/10 for Milk of Magnesia (laxative medication to relieve constipation).
- Psychiatric Technician/Security Aide Flowsheet for 08/14, that indicated the patient did not have a bowel movement (poop/stool) from 08/06/14 until 08/11/14; and
- Treatment plan dated 05/01/14, did not indicate problems, goals or interventions related to the patient's gastrointestinal system (pertaining to the stomach and intestines).

During an interview on 08/26/14 at 3:50 PM, Staff G, Lead Registered Nurse (RN), stated that the patient had very large bowel movements (stool/poop).

During an interview on 08/27/14 at 3:10 PM, Staff F, RN, along with Staff G, stated that Patient #6 had previously been placed on laxatives for constipation, but they didn't work, and that the patient's care plan did not include nursing interventions or goals for the patient's constipation because there was nothing they could do for the patient's constipation.

3. Observation on 08/27/14 at 9:40 AM, showed Patient #18 in the hall outside of her room in a wheelchair, her right foot was covered in a bulky bandage. The wheelchair wasn't equipped with attachments to elevate her legs.

Record review of Patient #18's Monthly Physician Progress Note, dated 08/07/14, showed:
- She had ongoing pain and was not able to walk due to right foot surgical procedures which included removal of her right great and third toes and removal of poor healing skin tissue in a skin ulcer.
- She received ongoing wound care to her right foot at the facility two times a day and also at a clinic outside the facility monthly.
- Cellulitis (skin infection from bacteria that had spread through the skin to deeper tissues) was present in her right lower leg.
- Her right leg was swollen and was leaking fluid from the skin surfaces.
- Her legs were to be elevated four to six times every day for 60 minutes.
- A urinary tract infection (UTI) was present and treated with two antibiotics (medication for the treatment of a bacterial infection).
- She had episodes of incontinence (had a loss or lack of bowel and/or bladder control).

During an interview on 08/27/14 at 9:40 AM, Patient #18 stated that:
- Her right foot, legs, back and neck hurt often.
- The nurses told her they would give her more pain medicine but they never did.
- The wounds on her feet hurt so bad at times, she "could hardly stand it."
- The medicine for the UTI caused loose stools and she could not get to the bathroom quick enough so she soiled herself and leaked urine.
- She did not remember if facility staff assisted or reminded her to use the toilet.
- She received wound care to her right foot and she did not elevate her legs often.

Record review of Patient #18's care plans dated 07/28/14, showed no identified problems, goals or nursing care for Patient #18's wound and skin care, pain/comfort, bowel and bladder problems (UTI), or cellulitis.

During an interview on 08/27/14 at approximately 2:15 PM, Staff Q, RN assigned to Patient #18, stated that there were no care plans developed for Patient #18's wounds, skin care, pain/comfort, bowel/bladder problems (UTI) or cellulitis.




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Based on observation, interview, record review and policy review, the facility failed to ensure that patients' nursing care plans were developed and kept current for two patients (#6, #18) of 11 patients whose medical records were reviewed for nursing care plan goals and interventions. This had the potential to affect all patients by failing to ensure that the patients' physical and psychological needs were met. The facility census was 94.

Findings included:

1. Record review of the facility's policy titled, "Treatment Planning and Documentation," revised 01/16/14, showed that the treatment planning process included the identification of problems and goals, and relevant interventions as determined by on-going assessments of patients' needs.

2. Record review of Patient #6's medical record showed the following:
- Admission orders dated 10/06/10 for Milk of Magnesia (laxative medication to relieve constipation).
- Psychiatric Technician/Security Aide Flowsheet for 08/14, that indicated the patient did not have a bowel movement (poop/stool) from 08/06/14 until 08/11/14; and
- Treatment plan dated 05/01/14, did not indicate problems, goals or interventions related to the patient's gastrointestinal system (pertaining to the stomach and intestines).

During an interview on 08/26/14 at 3:50 PM, Staff G, Lead Registered Nurse (RN), stated that the patient had very large bowel movements (stool/poop).

During an interview on 08/27/14 at 3:10 PM, Staff F, RN, along with Staff G, stated that Patient #6 had previously been placed on laxatives for constipation, but they didn't work, and that the patient's care plan did not include nursing interventions or goals for the patient's constipation because there was nothing they could do for the patient's constipation.

3. Observation on 08/27/14 at 9:40 AM, showed Patient #18 in the hall outside of her room in a wheelchair, her right foot was covered in a bulky bandage. The wheelchair wasn't equipped with attachments to elevate her legs.

Record review of Patient #18's Monthly Physician Progress Note, dated 08/07/14, showed:
- She had ongoing pain and was not able to walk due to right foot surgical procedures which included removal of her right great and third toes and removal of poor healing skin tissue in a skin ulcer.
- She received ongoing wound care to her right foot at the facility two times a day and also at a clinic outside the facility monthly.
- Cellulitis (skin infection from bacteria that had spread through the skin to deeper tissues) was present in her right lower leg.
- Her right leg was swollen and was leaking fluid from the skin surfaces.
- Her legs were to be elevated four to six times every day for 60 minutes.
- A urinary tract infection (UTI) was present and treated with two antibiotics (medication for the treatment of a bacterial infection).
- She had episodes of incontinence (had a loss or lack of bowel and/or bladder control).

During an interview on 08/27/14 at 9:40 AM, Patient #18 stated that:
- Her right foot, legs, back and neck hurt often.
- The nurses told her they would give her more pain medicine but they never did.
- The wounds on her feet hurt so bad at times, she "could hardly stand it."
- The medicine for the UTI caused loose stools and she could not get to the bathroom quick enough so she soiled herself and leaked urine.
- She did not remember if facility staff assisted or reminded her to use the toilet.
- She received wound care to her right foot and she did not elevate her legs often.

Record review of Patient #18's care plans dated 07/28/14, showed no identified problems, goals or nursing care for Patient #18's wound and skin care, pain/comfort, bowel and bladder problems (UTI), or cellulitis.

During an interview on 08/27/14 at approximately 2:15 PM, Staff Q, RN assigned to Patient #18, stated that there were no care plans developed for Patient #18's wounds, skin care, pain/comfort, bowel/bladder problems (UTI) or cellulitis.




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