HospitalInspections.org

Based on record reviews and interviews, the facility failed to ensure that nursing staff developed a comprehensive nursing care plan for each patient that reflects the patient's goals and meets the patient's current nursing care needs for 1 of 1 patients (Patient #1).

Record review of the facility medical record for Patient #1, dated 12/21/2023 to 02/26/2024 revealed the following information:

Nursing Care Plans, Dated 12/21/2023 to 02/26/2024
Section entitled: ASPIRATION RISK PROBLEM:
"Aspiration risk problem expected to: Improve/Resolve Target date: 02/29/24. Aspiration risk problem is: Stabilizing/Maintaining"

Further review of the nursing care plans revealed no evidence of nursing actions/ interventions related to the identified aspiration risk, and/or any evidence that nursing staff were analyzing and reviewing data regarding the patient's responses to the plan of care.


Record review of the facility Policy entitled: Documentation the Provision of Care; Last revised:12/2021, revealed the following information:
-Screening and Risk Assessment:
3. Nutritional Screening is performed for inpatients and any outpatients. Inpatient screenings are completed within 24 hours of admission. Positive screens are referred for nutritional evaluation.
4. Functional Screening is performed for inpatients and for any outpatients. Inpatient screenings are completed within 24 hours of admission. Positive screens are referred for physical therapy evaluation.
5. Risk of injury from falls is assessed for inpatients. Emergency department patients and surgical patients are assumed to be at high risk for falls and given appropriate assistance and supervision. Inpatients with positive screens are provided with appropriate supervision and injury reduction interventions.

-ASSESSMENT AND REASSESSMENT:
Registered Nurses (RNs) perform and document assessments. Licensed Practical Nurses/ Licensed Vocational Nurses (LPN/LVNs) and nursing assistants Patient Care Technicians (PCTs) may assist with assessments by collecting data and entering it into the EHR. RNs are responsible for reviewing and analyzing the data, drawing conclusions and taking appropriate actions.
-PLAN OF CARE:
Each clinician involved in the patient's care contributes to the Plan of Care by identifying problems; establishing goals; setting time frames and developing interventions.
Comprehensive assessment and screening, along with patient and family input, helps to identify patient-specific problems which are prioritized focus areas for this hospitalization.
The clinician assigns an expected outcome (Improve/Resolve, Stabilize/Maintain or Deteriorate) and target date for each problem added to the Plan of Care. For each problem added to the Plan of Care, the EHR will suggest the appropriate Physiological, Functional, Psychological or Health Behavior related interventions. The clinician will review and add the suggested interventions.

In an interview conducted on 03/18/2024 at 1:10 pm, the facility VP of Operations confirmed the above findings and the facility's deficient practice.