HospitalInspections.org

Based on record review and interview the facility failed to ensure a comprehensive care plan that is individualized, based on assessing the patient's nursing care needs, treatment goals in 7 of 10 patient care plans (Patient #1, 2, 6, 7, 8, 9, and 10) and failed to ensure staff follow their policies and procedures to update their care plans using current assessments and response to interventions in 5 of 10 patient care plans (Patient #2, 7, 8, 9, and 10) in a total of 10 patient medical records reviewed.

Findings include:

Review of policy "Restraints - Use of" revised 6/5/019 page 4 General Principles for Restraints 3. "Assess and reassess the patient's need for the use of restraint. Reassessment should occur on an ongoing basis... 4... involve the patient and parent/caregiver/family in the decisions and activities that relate to the use of restraints." Page 5 under Procedure Criteria for Restraint Use under non-violent revealed "RN assesses and documents that the patient is at risk for at least one of the following criteria: Removing invasive lines... Developmentally unable... or follow simple instructions... agitated." Page 13 under Nursing Staff will document in the patient's medical record: "Plan of Care: Modification made in plan of care."

Review of Patient Care Policy and Procedure "Assessment, Reassessment, Documentation of a Patient" revised 5/20/2019, page 13 under Care Plans revealed " The nurse is responsible for: 1. Adding patient specific care plans based on the patient's needs... 2. Selecting specific patient interventions and goals as individualized for the patient... 3. Reviewing and updating the care plan at a minimum of every 24 hours."

Review on 2/16/2020 at 11:08 AM of Patient #1's medical record revealed Patient #1 was intubated (breathing with tube), transferred from another acute hospital, and admitted to the Pediatric Intensive Care Unit on 12/19/2020 at 11:30 PM with the diagnosis of pneumonia of both lungs. Patient #1 was an 18-year-old with a medical history of Trisomy 21, attention deficit hyperactivity disorder (ADHD), and autism. The care plan had templates with actions and interventions for decreased cardiac output, fluid volume deficit, intubated patient, pain, and risk for impaired skin integrity but they were not individualized to Patient #1's needs. There was no care plan addressing Patient #1's autism, Trisomy 21, or cognitive functioning (understanding or thought process), he had increased agitation and had recently pulled out his breathing tube. This was confirmed with Manager West 4 A at the time of review.

Review on 2/26/2020 at 9:37 AM of Patient #2's medical record revealed Patient #2 was admitted to the Pediatric Intensive Care Unit on 12/21/2019 at 8:59 AM after being found unresponsive and seizing with the diagnosis of acute encephalopathy (swelling of the brain). Patient #2 is a 4-year-old with the past history of congenital adrenal hyperplasia (genetic disorder of the adrenal glands) admitted with seizures initiated by hypoglycemia (low blood sugar). Patient #2 died 12/26/2019 at 9:41 AM. The care plan had templates with actions and interventions for fluid volume deficit and risk for impaired skin integrity but they were not individualized to meet Patient #2's needs. There was no care plan update for 12/23/2019, 12/24/2019, 12/25/2019 or 12/26/2019. This was confirmed with Clinical Nurse Specialist (CNS) B at the time of review.

Review on 2/27/2020 at 11 AM of Patient #6's medical record revealed Patient #6 was admitted to the Pediatric Intensive Care Unit on 12/11/2019 at 8:36 AM with seizures. Patient #6 is a premature 10-month-old with a history of epilepsy, gastrojejunal tube (tube used for feeding) and chronic respiratory failure requiring a tracheostomy and home ventilation. The care plan consisted of a general plan of care and pain but they were not individualized to meet Patient #6's needs. This was confirmed with CNS B at the time of review.

Review on 2/27/2020 at 11:12 AM of Patient #7's medical record revealed Patient #7 was admitted to the Pediatric Intensive Care Unit on 12/01/2019 at 1:22 AM with abdominal pain and diarrhea and was discharged 12/03/2019 at 3:26 PM. Patient #7 is a 9-year-old with a history of liver transplant. The care plan consisted of a general plan of care but it was not individualized to meet Patient #7's needs. There was no care plan for pain. There was no care plan update for 12/02/2019. This was confirmed with CNS B at the time of review.

Review on 2/27/2020 at 12 PM of Patient #8's medical record revealed Patient #8 was admitted to the Pediatric Intensive Care Unit on 2/19/2020 at 1:44 AM with acute bronchiolitis requiring intubation for respiratory support. Patient #8 is an 8-month-old with no significant medical history. The care plan had templates with actions and interventions for delirium, intubated patient, general, and risk for impaired skin integrity, but they were not individualized to Patient #8's needs. There was no care plan update for 2/23/2020 or 2/26/2020. This was confirmed with CNS B at the time of review.

Review on 2/27/2020 at 12:40 PM of Patient #9's medical record revealed Patient #9 was admitted to the Pediatric Intensive Care Unit on 2/05/2019 at 9:26 AM with respiratory failure and hypoxia and discharged 2/08/2019 at 1:15 PM. Patient #9 was a premature 26 week old with a history of tracheostomy (hole for breathing), and gastrostomy (tube for feeding). The care plan had templates with actions and interventions for skin integrity, respiratory insufficiency, and general cares but they were not individualized to Patient #9's needs. There was no care plan update for 2/06/2020. This was confirmed with CNS B at the time of review.

Review on 2/27/2020 at 12:50 PM of Patient #10's medical record revealed Patient #10 was admitted to the Pediatric Intensive Care Unit on 1/17/2020 at 10:04 AM with acute bronchiolitis and acute respiratory failure and was discharged 1/19/2020. Patient #10 is a 18-month-old with a history of Hemophilia A (blood disease). The care plan had templates with actions and interventions for a general care plan only but they were not individualized to Patient #9's needs. There is no care plan for respiratory insufficiency. There was no care plan update for 1/18/2020 or 1/19/2020. This was confirmed with CNS B at the time of review.

On 2/27/2020 at 1:10 PM during an interview with Clinical Nurse Specialist B, CNS B stated their care plans were being updated this spring to require more individualization and nursing updates every shift. CNS B stated use of restraints were documented in the intubation care plan, but confirmed that their care plans were not individualized to the patient and updates were not always completed each shift as expected.