HospitalInspections.org

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Based on record review, nursing policy review and staff interview; the facility failed to develop a nursing care plan to meet the identified needs of the patient for 3 of 10 sampled patients (Patients 3, 4, and 8). The facility census was 76. This deficient practice had the potential to affect all patients admitted to the facility.

Findings are:

A. Record review of the facility policy titled "Patient Plan of Care" (last revised and approved 4/12/2016) states "Planning includes creating an initial plan for care, treatment and services appropriate to the patient's specific assessed needs and then revising or maintaining the plan based on the patient's response and goals".

B. Record review of Patient 8's medical record revealed the patient was admitted on 9/29/18. The physician History and Physical (H & P) dated 9/29/18, notes the patient was admitted from the emergency room where testing indicated need for emergency surgery. The patient was found to have a perforated gastric (stomach) ulcer requiring surgical repair. The H & P further noted the patient is a user of methamphetamine with the last injection the day before on 9/28/18. The H& P states "After surgery will address the patient's drug use and possible rehabilitation". Review of the patient's plan of care developed on 9/30/18 included a surgical plan of care and pain. On 10/1/18 an anxiety plan of care was implemented. The plan of care did not identify the patient as having a substance abuse problem or include interventions to assess for withdrawal and how this affects the patients pain management and discharge plans.

Interview with Registered Nurse (RN) A on 10/2/18 at 2:45 PM revealed the patient had some methamphetamine withdrawal problems yesterday stating the patient was screaming and yelling. Ativan, a medication used to treat anxiety, was given Intravenously. The nurse further stated that Dilaudid, pain medication, was given more frequently on 10/2/18. The nurse reported the patient is calmer today and using less Dilaudid. The nurse further stated that the discharge plan for the patient was to go home. Social work was going to notify Child Protective Services of the patients' methamphetamine use with children in the home. RN A confirmed the patient's substance abuse was not in the plan of care and stated "I don't know how to add it in the new Cerner (Electronic Medical Record system initiated in the facility 9/15/18) After interviewing the nurse, a plan of care was added on 10/2/18 to include Affect/Behavior.

Interview with the Medical Surgical Nursing Director on 10/2/18 at 2:30 PM revealed the nursing staff can pull a Behavioral Health Unit list of nursing care plans online to include a plan of care for substance abuse or can free text a customized problem. The Director confirmed the substance abuse should have been included in the plan of care.



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C. A review of the medical record for Patient 3 (admitted 9/29/18 and discharged 10/2/18) following hospitalization for grand mal seizures (A type of seizure when your body stiffens, jerks, and shakes and you lose consciousness) in the emergency department. Patient 3's Plan of Care and interventions addressed only Discharge Planning.

The medical record for Patient 3 lacked a Plan of Care for:
-Grand Mal seizure activity with interventions related to potential for injury; potential for seizure precautions; potential for ineffective airway; actual knowledge deficient.

An interview with Registered Nurse K (RN K) on 10/2/18 at 11:00 AM, verified that the medical record for Patient 3 lacked a seizure plan of care.

D. A review of the medical record for Patient 4 (admitted 9/30/18 and remains hospitalized ) for an Acute Urinary Tract Infection (A sudden onset of an infection that involves the bladder and urinary system) and Neutropenia (an abnormally low level of white blood cells important to fight off infections due to ongoing chemo therapy). Patient 4's Plan of Care and interventions addressed Impaired skin integrity; pain; and risk for falls.

The medical record lacked a Plan of Care for:
-An Acute Urinary Tract Infection with interventions related to the actual infection; potential for impaired urinary elimination; and actual knowledge deficiency.
-A Neutopenia Care Plan with interventions related to the use of protective isolation (the use of gowns, gloves, masks when in contact with the patient to protect the patient from potential infection by staff or visitors); knowledge deficiency.

An interview with RN K on 10/2/18 at 11:15 AM verified the medical record for Patient 4 lacked a care plan for the acute urinary tract infection and the neutropenia precautions.