HospitalInspections.org

Based on observation, interviews and record reviews the facility was not in compliance with the requirement to prepare Comprehensive Care Plans for 1 of 5 sampled patients #5.

The findings were:

On 7/29/10 a record review for patient #5 was done. This record review revealed that patient #5 was a hospice patient and had a Stage I pressure Ulcer to the coccyx. Further review of patient #5's medical record also revealed there was no care plan to address patient #5's wound and no care plan to addressing the fact that patient #5 was on hospice care.

On 7/29/10 at 11:45 a.m. an interview with the Chief Nursing Officer (CNO) was conducted. During this interview the CNO stated part of the plan of correction for this deficiency, was to do random chart audits twice weekly. The surveyor then asked the CNO what happened with patient #5's chart audit and why the appropriate care plans for wounds and hospice were not in place. The CNO stated, " well, I gues this patient's chart was not one of the charts we pulled for review." The surveyor asked why patient #5's chart was not pulled for review since the census, on average, has only been around 8 patients for the week. The CNO stated, "it was just an oversight."

This is the second follow up visit for this citiation and the surveyor could not clear the citation.



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