HospitalInspections.org

Based on record review and interview, the facility failed to develop and keep current nursing care plans for 12 (#s 1, 2, 3, 6, 7, 8, 11, 12, 13, 14, 16, and 17) of 20 sampled patients. Findings include:

1. Patient #11 was admitted on 6/8/15 in labor. A nursing care plan was not developed and kept current during her hospital stay.

2. Patient #12 was born on 6/9/15. A nursing care plan was not developed and kept current during her hospital stay.

3. Patient #13 was admitted in labor on 4/6/15 and delivered the same day. A nursing care plan was not developed and kept current during her hospital stay.

4. Patient #14 was born on 4/6/15. A nursing care plan was not developed and kept current during her hospital stay.

5. Patient #16 was admitted to the hospital in labor on 11/9/14 and had a delivery. A nursing care plan was not developed and kept current during her hospital stay.

6. Patient #17 was admitted to the hospital on 10/9/15 with fetal demise and had a cesarean section. A nursing care plan was not developed and kept current during her hospital stay.




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7. Patient #1 was admitted on 6/16/15 for a scheduled caesarean section. A nursing care plan was not developed and kept current during her hospital stay.

8. Patient #2 was born on 6/16/15. A nursing care plan was not developed and kept current during her hospital stay.

9. Patient #3 was admitted on 6/15/15 for a severe decubitus ulcer. A nursing care plan was not developed and kept current during his hospital stay.

10. Patient #6 was admitted on 6/15/15 for an intracerebral hemorrhage. A nursing care plan was not developed and kept during his hospital stay.

11. Patient #7 was admitted on 6/11/15 for suicidal ideation. A nursing care plan was not developed and kept during her hospital stay.

12. Patient #8 was admitted on 5/23/15 for shortness of breath, congestive heart failure, and anemia. A nursing care plan was not developed and kept during her hospital stay.

During an interview on 6/17/15 at 5:00 p.m., staff member C, RN, DON, stated when the hospital switched to their new EHR program, Cerner, they were not given the needed training to initiate care plans electronically, so they have not been done. He stated they didn't have hard copies of the care plans either.

During an interview on 6/18/15 at 8:15 a.m., staff member J, RN, stated the new EHR program has been a learning process and there might be some patients without care plans. They do not have hard copies of care plans, and they do have an interdisciplinary team "stand up" every day, so they are familiar with the care needs.

During an interview on 6/18/15 at 8:30 a.m., staff member I, RN, stated there are not care plans in the EHR, but they do go through an interdisciplinary care planning process everyday as part of the discharge planning process where the care needs of each patient are discussed.

During an interview on 6/18/15 at 8:45 a.m., patient #9 stated the care has been ok during her hospitalization, but she was not aware of a care plan.

Based on record review and interview, the hospital nursing staff failed to develop and complete a comprehensive plan of care with measurable goals and timelines for 2 (#s 5 and 18) of 5 sampled swing bed patients. Findings include:

1. Patient #18 was admitted to the facility with diagnoses of dementia and a urinary tract infection. Review of patient #2's electronic health record reflected there was not a comprehensive care plan developed.


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2. Patient # 5 was admitted to the facility with diagnosis of a rectal vaginal fistula. Review of patient #5's electronic heath record reflected there was not a comprehensive care plan developed.

During an interview on 6/17/15 at 5:40p.m. staff member C, DON, stated staff did not receive adequate training on generating care plans in the new EHR program, so the patients did not have plans of care in the electronic system and they did not have hard copies of the care plans either.

Based on record review and interview, the hospital nursing staff failed to develop a comprehensive plan of care within seven days after completion of the comprehensive assessment for 2 (#s 5 and 18) of 5 sampled swing bed patients. Findings include:

1. Patient #18 was admitted to the facility with diagnoses of dementia and a urinary tract infection. Review of patient #2's electronic health record reflected there was not a comprehensive care plan developed.


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2. Patient # 5 was admitted to the facility with diagnosis of a rectal vaginal fistula. Review of patient #5's electronic heath record reflected there was not a comprehensive care plan developed.

During an interview on 6/17/15 at 5:40 p.m. staff member C, DON, stated staff did not receive adequate training on generating care plans in the new EHR program, so the patients did not have plans of care in the electronic system and they did not have hard copies of the care plans either.