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UNIVERSITY OF MICHIGAN HEALTH
NURSING CARE PLAN
Tag No.: A0396
Based on record review and interview, the facility failed to ensure that the nursing staff develops and keeps current nursing care plans in 1 of 16 charts reviewed.(Patient #1) Findings include:
On 02/06/12 at approximately 1000 during record review for patient #1 it was determined that during the patient's hospitalization from 02/03/11 to 02/15/11, the nursing care plan was not updated on 02/04/11, in regards to patient allergies. According to the History & Physical dated 02/03/11 and the Discharge Summary dated 02/15/11, it was known that the patient did have a "latex allergy if internalized".
Ultimately, latex precautions were added to the care plan: a sign placed on the door, signs posted at the bedside, the chart was flagged for the specific allergy and latex free supplies were placed at the bedside.
The Director of Quality Improvement/Accreditation Readiness confirmed that the facility nursing staff did not update the patient's care plan and did not follow the care plan policy on 02/04/11.