HospitalInspections.org

Based on staff interview and review of medical records and hospital policies, it was determined the CAH failed to ensure complete nursing care plans were developed for 5 of 11 patients (#1, #2, #5, #7, and #11) whose medical records were reviewed. This interfered with the CAH staff's ability to provide consistent patient care. The findings include:

1. Patient #1's medical record documented a 19 year old male who was admitted to the hospital on 11/24/09. He was discharged on 11/25/09. His History and Physical Examination, dated 11/24/09, stated his diagnosis was peritonsillar abscess and dehydration. His tonsils were surgically removed on 11/24/09. His medical record contained a blank nursing POC. This was confirmed by interview with the DNS on 1/26/10 at 4:05 PM.

2. Patient #2's medical record documented a 30 year old male who was admitted to the hospital on 10/19/09. He was discharged on 10/22/09. His History and Physical Examination, dated 10/19/09, stated his diagnoses included spina bifida, hydro-ureter with a history of recent ureterostomy surgery, abdominal pain, hydronephrosis, and blood clots to his lower extremity. The only problem listed on his nursing POC, dated 10/20/09, was "Risk for further blood clots [related to] non-therapeutic [laboratory] results." His kidney problems and pain were not addressed. This was confirmed by interview with the DNS on 1/26/10 at 4:05 PM.

3. Patient #5's medical record documented a 45 year old female who was admitted to the hospital on 10/02/09. She was discharged on 10/05/09. Her History and Physical Examination, dated 10/02/09, stated her diagnosis was abdominal pain. Her medical record did not contain a nursing POC. This was confirmed by interview with the DNS on 1/26/10 at 4:05 PM.

4. Patient #7's medical record documented a 56 year old male who was admitted to acute care services at the hospital from swing bed status on 4/03/09. He was transferred to another hospital on 4/08/09. His discharge summary, dated 4/08/09, listed his discharge diagnoses as chronic obstructive pulmonary disease and atrial fibrillation. The discharge summary stated he was readmitted to acute care services for an "Acute colonic pseudo obstruction." The summary stated he had a nasogastric tube and a rectal tube. Patient #7 had a Kardex which listed the rectal tube, oxygen orders and other ongoing orders. His medical record did not contain a nursing POC. This was confirmed by interview with the DNS on 1/26/10 at 4:05 PM.

5. Patient #11's medical record documented a 78 year old female who was admitted to the hospital on 11/14/09. She was discharged on 4/08/09. Her discharge summary, dated 11/24/09, stated she had colon and gallbladder surgery on 11/14/09. Following surgery, the discharge summary stated she had a nasogastric tube and operative drains. The discharge summary stated she had a period of confusion following surgery. Patient #11 had a Kardex which listed the post-operative orders. She did not have a nursing POC. This was confirmed by interview with the DNS on 1/26/10 at 4:05 PM.

6. The DNS was interviewed on 1/26/10 at 4:05 PM. She stated the hospital did not have a current policy that addressed POCs.

The hospital did not maintain complete nursing POCs.