HospitalInspections.org

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Based on document review, Medical Record review and interview in three (3) of seven (7) Medical Records, the Nursing Staff failed to consistently develop, and revise Nursing Care Plans related to the patients' nursing care needs.

This failure of developing and revising the Nursing Care Plans may lead to delays in or a lack of treatment and care.

Findings include:

The facility's Policy and Procedure titled "Multidisciplinary Plan of Care (POC)" last revised May 2019, stated the following: "The plan [of care] is based on assessing the patient's care needs ... documentation of these needs may be found in the Plan of Care Flow Sheet, Assessment and Intervention Flow Sheet and Profile. The ... POC is kept ongoing and updated by the registered nurse ... Clinical Practice Guidelines (CPG) are part of the care planning process and are selected on the unique needs of the patient. The ... POC is formulated and modified for all patients. This plan is used ... to guide the delivery of care for the patient and to document the patient's progress ...."

The facility's current EMR (Electronic Medical Record) Education Manual titled "Nursing Clinical Documentation" included instruction for the Nursing Staff to "select the desired flowsheet ... [and] customize the flowsheet by adding parameters ... select a CPG and attach it to the Plan of Care ... individualize the POC with patient specific information ... review the POC at the start of shift ... (and) evaluate the CPG's for continued applicability ... the POC must be updated on admission and daily ...."

Review of Patient #8's Medical Record identified the following information: This 71-year-old was admitted from the skilled nursing facility on 05/10/19 after he was successfully resuscitated for cardiac arrest. The patient had a past medical history of Hypertension, Chronic Obstructive Pulmonary Disease, Seizure Disorders, Cerebral Vascular Disease, Sacral Ulcer and Parkinson's. The patient was dependent on mechanical ventilation via a tracheostomy tube and receiving nutritional feeding by PEG (Percutaneous Esophageal Gastrostomy) prior to the cardiac arrest. The patient was treated in the emergency room with intravenous medications and intravenous antibiotics, then admitted to the Intensive Care Unit with a diagnosis of Sepsis, due to a Urinary Tract Infection.

There was only one (1) Clinical Practice Guideline (CPG) for Sepsis included in the Adult Plan of Care documented on 05/10/19. There were no other CPG's related to additional diagnoses documented on the POC by the Nursing Staff for this patient from 05/10/19 to 06/11/19.

Review of the Adult Assessment and Intervention (A&I) Flow Sheets identified that the Flow Sheets lacked aspiration precaution assessment and interventions related to the tracheostomy and PEG tube but were indicated by the CPG's for both an Artificial Airway and Enteral Nutrition.

Although the A&I Flow Sheets contained documentation that the patient had a Tracheostomy, the A&I Flow Sheets did not contain documented evidence that the patient was receiving Tracheostomy care. This was also indicated by the Artificial Airway CPG and the Nursing Outcome Summary Progress Notes, which lacked documentation that tracheostomy care had been provided consistently.

Additionally, the Nursing Staff did not initiate the CPG for Seizures and did not revise the A&I to include seizures precautions for this patient who has a history of a Seizure Disorder receiving anti-seizure medication.

Neither the CPG's nor the A&I's accurately reflected the nursing care needs of this patient.

Per interview of Staff L (Nursing Director) on 06/12/10 at 10:30AM, Staff L stated, "The Nursing Staff is instructed to choose the most pertinent CPG related to the patient's diagnosis and add it to the Adult Plan of Care. The Assessment and Intervention Flow Sheet (A&I) is also part of the patient's Care Plan and should include the nursing care the patient is receiving."

The same lack of documentation of a complete and revised Nursing Care Plan was found in the Medical Records of Patients #1 and #7 for the review period of 06/10/19 to 06/12/19.

These findings were acknowledged by Staff A (Nursing Administrator), Staff L (Nursing Director), and Staff M (Nursing Administrator) at 11:00AM on 06/12/19.