HospitalInspections.org

Based on record review, interview, and policy review, the provider failed to care plan individualized patient care for one of one sampled patient (18) admitted into acute care from the emergency department (ED). Findings include:

1. Review of patient 18's medical record revealed:
*She had been admitted into acute care on 10/25/15 at 4:30 p.m. from the ED.
*She had a pressure ulcer (injury to skin due to unrelieved pressure) to her coccyx.
*She was discharged from the ED to acute care with the following diagnoses:
-Sepsis (life threatening condition due to infection) due to unspecified organism.
-Urinary tract infection (UTI).
-Rash.

Review of the acute care physician's notes regarding patient 18 revealed:
*On 10/25/15 the active hospital problems were sepsis, acute cystitis (bladder infection) without hematuria (blood in urine), malnutrition, UTI, skin desquamation (skin peeling), and delirium (confusion).
*On 10/26/15 the delirium had resolved, but the other issues were still being addressed.
*On 10/27/15 she had diarrhea and was tested for Clostridium difficile (C-diff.) The test result was negative.
*On 10/28/15 she had been positive for C-diff and started on an antibiotic. She was also anemic.
*On 10/29/15 she had passed away.

Review of patient 18's nurses progress notes revealed on 10/26/15 she had been put under contact precautions due to a history of having several communicable diseases.

Review of patient 18's undated care plan revealed it had not addressed the following:
*Sepsis.
*UTI.
*C-diff.
*Isolation.

Interview on 4/20/16 at 2:00 p.m. with the chief nursing officer, chief financial officer (in place of administrator's absence), and the director of medical/surgical revealed the above mentioned items had not been identified on the patient's care plan. They agreed those were issues she had while a patient at the hospital.

Review of the provider's 11/10/15 Documentation Nursing policy revealed:
*The admitting assessment should have been used to develop and coordinate the plan of care.
*The plan of care was to be documented and revised as needed by all disciplines.
*Critical reasoning should have been reflected in the plan of care.
*Notes would have been used to document progress.
*The plan of care was to be updated throughout the stay as needed.
*The plan of care should have included goals and interventions.