HospitalInspections.org

Based on interviews, record and policy review, the facility failed to follow their Nursing Care Plan policy when staff failed to incorporate a nursing care plan that addressed all patient needs that included measurable goals, interventions and time tables for four (#4, #5, #13, #14) of five patients reviewed. This failure had the potential to deny all patients admitted to the facility care based on their individual needs. The facility census was 14.
Findings included:
1. Record review of the facility policy, "Nursing Care Plan", dated 11/13, showed:
- The RN (Registered Nurse) is responsible for initiating a (written) guide for the patient's plan of care from admission to discharge according to adopted Nursing Standards of Practice.
- The plan is updated and revised periodically based on evaluation of patient progress/achievement of goals.
- Identify problems, needs or concerns.
- Based on review and analysis of data collection/assessment, determine patient's actual or potential nursing needs/problems/concerns.
- When using standardized care plans they will be individualized for each patient.

2. Record review of the History and Physical Examination (H&P) for Patient #4 showed she was admitted to the facility on 10/03/14 with chest pain suspicious of coronary syndrome (conditions due to decreased blood flow in the vessels that supply the heart muscle with blood rich in oxygen such that part of the heart muscle is unable to function properly or dies), congestive heart failure (heart has decreased ability to pump blood through the heart), hypertension (high blood pressure) urinary frequency and incontinence (unable to control urine) and episodic (random occurring) disorientation. Review of the Patient Care Plan showed an identified need for infection prevention added to the Care Plan on 10/06/14, three days after admission. The interventions for infection prevention included limiting patient visitors and traffic control however there was no indicated need for isolation precautions and there was no mention of the risk of infection due to a Foley catheter (tube inserted into the urinary bladder) inserted on 10/03/14. A care plan was added for potential for injury related to wandering/elopement on 10/06/14 at 11:01 AM, three days after admission when the patient was assessed as having periodic disorientation on admission and ambulated independently.

3. Record review of the H&P for Patient #5 showed she was admitted to the facility on 10/03/14 at 11:19 AM with a compression fracture of the lumbar spine for pain relief, physical therapy (PT) and occupational therapy (OT). Review of the clinical progress notes for PT/OT showed she was evaluated by the Occupational Therapist on 10/04/14 at 2:29 PM and identified as having self-care deficits. There were no PT or OT goals or interventions entered on the Patient Care Plan.

4. Record review of the H&P for Patient #13 showed he was admitted to the facility on 10/05/14 with acute congestive heart failure. The patient had a Foley catheter inserted in the Emergency Department (ED). He was started on oral pain medications as needed, intravenous (IV, through a small tube inserted into a vein) antibiotics, a diuretic (reduces excess fluid levels in the body) and an anticoagulant (blood thinner). Review of the Patient Care Plan showed an identified risk for infection. The interventions for infection control included limiting visitors and traffic control however the patient was not on isolation precautions. The interventions did not include infection control measure related to Foley catheter or his IV. There was no care plan initiated for pain control or the safety risks associated with anticoagulation therapy.

5. Record review for Patient #14 showed she was admitted to the facility on 10/05/14 with urinary tract infection (bladder infection), fever and hypotension. The nursing admission assessment dated 10/05/14 at 9:23 PM, showed the patient was blind and unresponsive (does not respond to stimulation). She was incontinent of the bowel and bladder and a Foley catheter had been inserted in the ED prior to admission. The patient was placed on Comfort Measures (supports a dignified, comfortable death without life sustaining interventions). Review of the Patient Care Plan showed an identified need for infection prevention. The interventions for infection prevention included limiting patient visitors and traffic control however there was no indication that patient was on isolation precautions and there was no mention of the risk due to the Foley catheter. The patient was blind however there was no plan for sensory deprivation (removal of one or more external stimuli with regards to the five senses: sight, sound, touch, taste and smell) or alternative communication needs. There was no care planning for risk of skin breakdown due to her incontinence, malnutrition, and immobility due to her unresponsive state.

During an interview on 10/06/14 at 10:40 AM, Staff C, RN, stated that:
- Care associated with a Foley catheter would be identified under potential risk for infection.
- All patient care plans included the risk for infection and that the interventions or risk for infection were to follow hand hygiene policy, implement protective measures to prevent infection, limit patient visitors and initiate traffic control, and maintain sterile technique for all invasive procedures for every patient.
- Her patients were not on isolation precautions, she did not restrict visitors and she did not have the ability to individualize the care plan interventions for her patients.

During an interview on 10/06/14 at 11:10 AM, Staff D, RN, Charge Nurse, stated that:
-Patient #13 was not in isolation and she was not sure why they would limit visitors or initiate traffic control for him.
- The care plan goals and interventions were auto-populated and the nurses were unable to select individualized patient interventions.
- The care plan software included a nursing diagnosis for infection control related to Foley catheter care and that she did not know why the nursing staff was not using it.
- The Patient Care Plan was a multidisciplinary tool and PT and OT were expected to enter their goals and interventions into the patient care plan.

6. Record review of the Care Plan Audit Tools showed no audit tools had been initiated for Patients #4, #5, #13, and #14.

During an interview on 10/07/14 at 1:20 PM, Staff B, RN, Chief Nursing Officer (CNO), stated that:
- She was behind with her daily chart audits for care plans.
- She "hadn't had time" to do them.
- She had not "figured out" how to do the audits on the weekends.
- She was aware the corrective action plan for deficiencies cited during the previous survey stated she or her designee were responsible for the audits.
- She had not designated anyone and stated she would "tomorrow."
- Staff was not able to free text within the care plans to individualize them and that Information Technology (IT) was still working on the issue.

During an interview on 10/07/14 at 2:00 PM, Staff D, RN, stated that the staff did not have a way to individualize patient care plans and were only able to choose from the problem list that was available. She stated that IT was still working on the issue.

During an interview on 10/07/14 at 2:25 PM, Staff O, Certified Occupational Therapy Assistant (COTA), stated that she was able to free text in the patient's care plan and stated that IT had shown her how a few weeks ago.















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Based on interview and record review the facility failed to ensure History and Physical (H&P) examinations were documented (completed, dated, timed and signed) within 24 hours of admission in two (#4, #14) of four current and one (#10) of four discharged patient medical records reviewed. These failures to maintain timely documentation had the potential to cause miscommunication regarding patient care between the admitting physician and other health care professionals who contributed to the patient's care. The facility census was 14.

Findings included:

1. Record review of the facility's "Medical Staff By-Laws," dated 02/14 showed the attending practitioner shall be responsible for the preparation of a complete medical record for each patient. An inpatient H&P shall be completed no more than 24 hours after admission.

Record review of the facility's policy "Medical Record Content/Timeliness," dated 08/14 showed a complete H&P must be documented within 24 hours of admission.

2. Record review of the medical record for current Patient #4 showed she was admitted to the facility on 10/03/14. As of 10/06/14 there was no H&P documented on the medical chart.

3. Record review of the medical record for current Patient #14 showed she was admitted to the facility on 10/05/14. As of 10/07/14 at 3:30 PM there was no H&P documented on the medical chart.

4. Record review of the medical record for discharged Patient #10 showed she was admitted to the facility on 09/23/14 and discharged on 09/28/14. As of 10/07/14 there was no H&P documented in the medical chart.

During an interview on 10/07/14 at 9:45 AM, Staff N, Supervisor of Health Information Management (HIM) department stated that physicians were required to dictate an inpatient H&P within 24 hours of admission. She stated that an H&P entered into the EMR (Electronic Medical Record) system was available almost immediately and that turnaround time for a dictated H&P was less than half a day. She stated that the records reviewed should have included a current H&P.

Based on interview and record review the facility failed to ensure patient medical records contained dated and/or timed physician's signatures on orders in two (#10, #13) of three current and two (#17, #18) of four discharged patient medical records reviewed. This deficient practice had the potential to cause unintended, misunderstood physicians orders to be used in patient care. The facility census was 14.

Findings included:

1. Record review of the facility's "Medical Staff Rules and Regulations," dated 02/14 directed the following:
- All medical record entries shall be accurately dated, timed and authenticated.
- All orders shall be entered into CPOE (Computerized Physician Order Entry) of the EMR (Electronic Medical Record) or in writing, and dated, timed and authenticated the next time the prescribing Practitioner provides care to the patient, or documents information in the patient's medical record, OR within forty-eight hours, whichever is earliest.
- The ordering Practitioner must date and time the order at the time he or she signs the order.

2. Record review of the Physician's Orders for current Patient #10, showed the following orders entered into CPOE not dated, timed or signed by the physician:
- On 09/24/14 there were nine telephone orders;
- On 09/25/14 there were two telephone orders;
- On 09/26/14 there were four telephone orders;
- On 09/27/14 and 09/28/14 there was one telephone order each day.

3. Record review of the Physician's Orders for current Patient #13 showed written admission orders by the Emergency Department physician dated 10/05/14 but not timed.

4. Record review of the Physician's Orders for discharged Patient #17 showed the following orders entered into CPOE and not signed by the physician until 09/29/14:
- On 09/09/14 there were three verbal orders;
- On 09/10/14 there were five verbal orders and one telephone order; and
- On 09/11/14 there were four telephone orders.

5. Record review of the Physician's Orders for discharged Patient #18, showed the following orders entered into CPOE not dated, timed or signed by the physician:
- On 09/10/14 there were eight verbal orders;
- On 09/11/14 there were two verbal orders;
- On 09/13/14 there were three telephone orders; and
- On 09/14/14 there were five telephone orders.

During an interview on 10/11/14 at 9:45 AM, Staff N, Supervisor of Health Information Management (HIM) department, stated that physician's were required to sign, date and time their orders and physicians were required to sign their telephone/verbal orders (TO/VOs) within 48 hours.