HospitalInspections.org

Based on record review, policy review, and staff interview, it was determined the hospital failed to ensure nursing staff developed, or kept current, a nursing care plan for 2 of 9 patients (#3 and #9) whose medical records were reviewed. This failure resulted in missing or incomplete care plans, and had the potential to interfere with quality and coordination of patient care. Findings include:

The policy "Interprofessional Plan of Care," dated 4/04/17, stated:

- "All patients admitted to [hospital name] will have a Plan of Care."
- "Plan of Care includes the Interprofessional Plan of Care (IPOC) section in Cerner, Patient Care Orders, Handoff Forms and paper treatment plans/clinical pathways."
- "IPOCs will be individualized for every patient."
- "An outcome is the targeted goals of the IPOC."
- "Interventions: 1. Interventions are used for achieving the goal or outcome. 2. Interventions must be selected when initiating an IPOC. a. Additional interventions can be added any time during the plan of care."

The policy was not followed. Examples include:

1. Patient #9 was a 78 year old female admitted to the Rehabilitation Unit on 11/01/17, for care related to a CVA. She discharged to home on 11/10/17.

The initial rehabilitation nursing "Admission Profile," dated 11/01/17, included a Morse Fall Scale. It stated Patient #9 had a history of falling, used an "ambulatory aid - crutches/cane/walker," and had an impaired gait.

A second nursing clinical note, dated 11/01/17, stated Patient #9 had "slight R [right] sided weakness. Up with one and a walker."

Patient #9's record included a "History & Physical," dated 11/01/17. It stated Patient #9 required "contact guard assist for transfers" and "contact guard assist for toilet transfers."

Nursing documentation, dated 11/01/17, included implementation of "Environmental Safety Measures." The safety measures documented included adequate room lighting, use of bed alarm, bed in locked/low position, call light within reach, instruction to not get out of bed without assistance, non-skid footwear use, room free of clutter and trip hazards, and have bed side rails up x 2.

A nursing "Direct Charting Flowsheet," documented Patient #9 was educated on 11/01/17 in safety measures, including use of the call light, use of non-skid footwear, removal of clutter, and waiting for assistance.

Patient #9's IPOC addressed falls as follows:
"Plan: Fall Risk IPOC
Outcome: Will remain free from falls
Intervention: Assess risk factors for falls
Intervention: Assess ambulation"

The care plan did not address specific interventions to prevent Patient #9 from falling, such as contact guard assist for transfers, use of an ambulatory aid, implementation of environmental safety measures, and patient education.

An RN Clinical Informatics Specialist was interviewed on 12/28/17 at 9:12 AM. She reviewed Patient #9's record and confirmed the care plan did not address fall prevention interventions. The RN Clinical Informatics Specialist stated nursing staff and therapy staff kept the plan updated on a white board (a dry erase board) in patient rooms. She stated since March of 2017, PT notes could not be moved into the electronic care plan.

The Manager of the Rehabilitation Unit was interviewed on 12/28/17 at 9:15 AM. She stated nursing staff knew the plan of care by a verbal hand-off report, what is written on the white board in patient rooms, and by reading past nursing notes and PT notes. She stated the care planning process was not necessarily reflective of the hospital policy, particularly because PT notes "did not pull into IPOC."

An RN Supervisor in the Rehabilitation Unit was interviewed on 12/28/17 at 9:30 AM. She stated the care plan was discussed verbally at team conferences once a week. She stated some interventions were documented in the "education tab" which were not necessarily in the care plan. She stated, in order to know the current care plan, nursing staff would review PT notes daily.

A PT Supervisor was interviewed on 12/28/17 at 10:40 AM. She stated therapists do not document in IPOC. "It changed this year." She stated therapists documented on white boards in patient rooms and in their progress notes. She stated "IPOC is not the reference tool that reflects our practices. The white board is kept current."

Patient #9's nursing care plan was incomplete and did not include interventions used for achieving the goal of preventing falls.



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2. Patient #3 was a 79 year old male admitted to the hospital on 11/08/17, for a CVA. Additional diagnoses included uncontrolled DM Type II, gait abnormalities post CVA, dysphagia (difficulty swallowing), HTN, and smoking. He was discharged to home from on 11/10/17.

Patient #3's record was reviewed on a computer with an RN Clinical Informatics Specialist beginning at 2:30 PM on 12/27/17. His record did not include a nursing care plan.

The RN Clinical Informatics Specialist confirmed Patient #3's record did not include a nursing care plan.

Patient #3 did not have a nursing care plan.