HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current, individualized and comprehensive nursing care plans. This deficient practice was evidenced by failure of the nursing staff to include all problems, goals and interventions for 3 (#2, #3, #5) of 5 (#1 - #5) total patients sampled for care planning.

Findings:

Review of the hospital policy titled Interdisciplinary Treatment Planning presented as current policy revealed in part, the purpose is to ensure plans for care, treatment and services are individualized to meet the patient's needs and circumstances.

Patient #2
Review of the medical record of Patient #2 revealed a 58 year old admitted on 05/15/19 under a PEC and CEC with a history of depression admitted for suicidal ideation.
Further review of her medical record revealed she was admitted from the hospital (she was awaiting medical clearance) after a 3 night stay where she was treated for pneumonia, urinary tract infection and bladder spasms.

Review of Patient #2's orders revealed in part, the following admission orders:
Augmentin 875 mg PO Q 12 hours (for infection); and
Pyridium 100 mg PO daily (for bladder spasms).

Review of #2's nursing care plan revealed no documented evidence a care plan was developed and implemented for her infections.


Patient #3
Review of the medical record of Patient #3 revealed a 79 year old admitted on 01/29/19 under a PEC and CEC with a history of dementia admitted for agitation and hallucination.
Further review of his medical history revealed he had the diagnoses of Diabetes Mellitus and Urinary Tract Infection.
Patient #3 was discharged on 02/12/19.

Review of Patient #3's orders revealed in part, the following orders:
01/29/19 at 4:26 p.m. Cipro 500 mg PO BID (for UTI);
01/29/19 at 11:09 p.m. Amaryl 2 mg PO daily (for diabetes);
01/29/19 at 11:09 p.m. Glucophage 1000 mg PO BID (for diabetes);
01/31/19 at 11:02 a.m. accucheck ac and hs; and
02/09/19 at 3:05 p.m. Humulin R SQ sliding scale ac and hs.

Review of Patient #3's whole blood glucose lab values resulted in a range between 58 and 172 mg/dl.

Review of Patient #3's nursing care plan revealed no documented evidence a care plan was developed and implemented for his Diabetes Mellitus nor his Urinary Tract Infection with a foley catheter.


Patient #5
Review of the medical record of Patient #5 revealed a 75 year old admitted on 12/15/18 under a PEC and CEC with a history of depression admitted for suicidal ideations.
Further review of his medical history revealed he had a diagnosis of Diabetes Mellitus.
Patient #5 was discharged on 12/21/18.

Review of Patient #5's orders revealed in part, the following orders:
12/16/18 at 9:07 a.m. Amaryl 2 mg PO daily (for diabetes);
12/16/18 at 9:27 a.m. Insulin Glargine 15 units SQ daily (for diabetes);
12/16/18 at 5:25 p.m. Blood Glucose Monitoring BID (7:00 a.m. and 9:00 p.m.); and
12/17/18 at 7:00 a.m. Humulin R SQ sliding scale ac and hs.

Review of Patient #5's whole blood glucose lab values resulted in a range between 149 and 257 mg/dl.

Review of Patient #5's nursing care plan revealed no documented evidence a care plan was developed and implemented for his Diabetes Mellitus.


In an interview on 05/21/19 at 10:15 a.m. with S4RN, she stated the nurses do not place the patients' medical diagnoses which are related to maintenance medication and treatments on the care plan because these are the patients' baseline. She further stated they put in the patients' care plan the behavioral admitting diagnosis and goals.

In an interview on 05/21/19 at 1:15 p.m. with S2CNO and S3QD verified the care plans for the behavioral health unit do not include medical diagnoses even if the patient is on medication for their medical condition because this is considered standard. It was further revealed they focus on the top 3 mental health problems which can be treated while in the behavioral health unit.