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Based on review of patient records and interview with the patients family member the facility failed to actively include the patient and /or her family in developing, implementing or revising the care plan to increase her dietary intake, increase her protein intake, teach off loading or teach prevention for skin break down in a patient with multiple disease processes..

Review of 1 of 1 patient records indicate the medical portion of the plan of care was limited to explanation of surgical intervention. There was no documentation of sharing with the patient or her family information regarding the risks that surgery would change the patient's ability to participate in her activities of daily living. There was no documentation the patient or family was made aware of the potential risk for pressure wound development related to the surgical removal of the patients right leg and later the removal of the left leg.

The nursing portion of the care plan dated 3/5/2010 "A" Safety: under the column for PROBLEMS "Fall Risk Identified" is marked, however "Lack of Knowledge to Room, Call light system, Bed controls, Cell phones, Phones, Valuables, Side rails, Smoking Safety and Medications" is not marked for a newly admitted patient. In the column identified as INTERVENTIONS: "Discussed Hospital policy with patient and family to ensure safety/comfort" is marked. There is no documentation as to what that policy says. "Call light in Reach" is marked and "Fall Risk Prevention Initiated" is marked. The column for GOALS/OUTCOMES has "Patient/family oriented to environment and cognizant of policies". Yet the lack of knowledge to room and environment is not marked in the problems column. The patient sustained an unwitnessed fall on 4/20/2010. There is no documentation the care plan was up dated with new interventions for falls.

The nursing care plan section "G" Psychosocial: the column under PROBLEMS; a box is marked next to Ineffective Coping. There is no documentation to support what coping was observed to be ineffective. Under the column of section 'G" for INTERVENTIONS Facilitate patient/family communication is marked. There is no documentation indicating how this is to occur. Also AGE-APPROPRIATE INTERVENTIONS is marked and 73 years is written out to the side. There is no documentation to support appropriate interventions. The next intervention marked is patient teaching. "Instruct patient to use call light for any needs" is written.

There is documentation in the nurses notes dated 3/22/2010 timed for 2020 stating " Passed formed stool. Skin care done. Skin Breakdown noted to buttocks. Repositioned off back, denies pain". No intervention is documented by the nurse. There is no nursing documentation that the physician or family was to be notified or that the care plan was updated at that time. The is no wound care entry to the care plan regarding the skin break down until 4/12/2010 under section "K" PAIN " under the PROBLEMS column "Coccyx area Stage 3"is written. The care plan does not reflect the skin break down until 4/15/201 in Section "L" Integumentary "Stage IV coccyx" appears in the problem section of the care plan. In the INTERVENTION column The following are listed 1) Refer to WOC Nurses 2) dry dressing daily 3) turn q2
4) educate nursing and PCA staff on specialty bed. There is no documentation the family was educated as to the start of the skin break down or any intervention.

Interview with the patient's son confirmed the lack of family teaching regarding changes in mobility related to surgical amputation. No teaching was done by nursing service on an ongoing basis to reinforce repositioning, improve protein intake and nutrition in general. No explanation of the healing requirements of the human body were given to the family.

Interview with the patient's spouse, who was at his wife bedside the majority of the hospitalization, confirmed he was not aware of care planning for his wife until time for her to be discharged.

Based on record review and interview the facility failed to insure patient safety and failed to notify the patients family after a fall from the bed to the floor.



At 11:00 on 5/25/2010 the patients record was reviewed. Documentation on 3/28/2010 confirmed the patient was discovered on the floor at approximately 11:00 PM. She was found by a nurses aid. The nursing staff assessed the patient noting no injuries and replaced her in to her bed. Nursing staff notified the Doctor and carried out orders that were received, however, the patients spouse was not notified until 8:00 AM the next morning.

The facility policy was reviewed for content and there was found no instruction to the nursing staff for notifying the family of a patient after a fall.

Documentation for the fall was recorded in the risk managers records.


Interview with the patient's spouse on 5/24/2010 confirmed he was not notified until 8:00 AM the morning after his wife was found on the floor by her bed.

An interview with staff #1 at 11:35 on 5/25/2010 confirmed there was no guidance to the nursing staff in their policy for falls. This surveyor asked staff #1 if it was their policy NOT to notify the patient's family at the time of the fall? She stated it was understood the nurse was to notify the family as soon as possible and the nurse who had failed to notify the family had been counseled. However at the time of the survey no documentation had been submitted as evidence of investigation, training or counseling of any nursing staff involved in this event by the facility.

Based on record review and interview the facility failed to implement care planning for 1 of 1 pts as evidenced by inadequate assessment and lack of documentation.

A review of the patient's medical records revealed numerous nursing assessment errors and/or failures to documentation.
Examples:
3/6/2010 Patient Care Flow sheet shows no documentation for Eating/Feeding, Bathroom/Bed Side Commode, Turned Left/Right/Back. The Fall Risk assessment had no documentation for incontinence or frequency for any shift.
3/8/2010 Turning Left/Right Back is documented as "self" however the documentation also reflected incontinence in all shifts.
3/9/2010 Documentation reflected the patient ate at 9 AM no other nutritional intake noted on the Flow sheet. The Fall Risk assessment is incomplete with no documentation for Impairment, Mental status or Elimination.
3/11/2010 It is documented in the nurses notes the patient states " She has had diarrhea all day because she is uptight about her surgery tomorrow" the Patient Care Flow sheet did not record any elimination during the day shift and only one episode during the night. There was no documentation for intervention for the patients anxiety related to her surgery. There was no documentation of the patient's position Left/Right or Back. The Fall Risk assessment is incomplete as well as the Fall Risk Interventions.
.3/12/2010 There was no documentation for Resting Sleeping, Eating/Feeding and the Fall Risk assessment is incomplete having no documentation for the 7p-7a shift in either the assessments or interventions section.
3/13/2010 There was no documentation for AM nutritional intake, no documentation for Turning, and the Fall Risk assessment and Fall Risk Intervention was incomplete with no documentation for the 7p-7a shift.
3/14/2010 In the nurses notes narrative at 1850 PM documentation indicated the patient was assisted with supper. (No percentage of intake indicated) The Patient Care Flow sheet did not indicate nutritional intake for 1830 PM. The documentation indicates repositioning for Back, Back, Right , Right for the first 4 hours of the shift and none afterward.
This pattern was continued throughout the patient's hospitalization.

An interview at 10:30 on 5/25/2010 with staff #1 confirmed the above documentation was incomplete.