HospitalInspections.org

Based on document review, and staff interview, the Critical Access Hospital (CAH) administration failed to ensure nursing staff developed and followed an accurate care plan for 1 of 1closed medical records (patient #1) of patients that acquired a wound during their hospital stay. The CAH staff identified 13 current inpatients.

Failure to develop and follow an appropriate care plan could potentially lead to patients not receiving required care, and lead to complications such as pressure wounds.

Findings include:

1. Review of the policy, "Care Planning Policy and Procedure", revised 10/28/09, revealed in part, "On admission ... the nurse will make complete [sic] an Initial Interview, Initial Risk Assessment and Initial Physical Assessment of the patient. This assessment will be used to develop ... a care plan specific to the patient."

2. Review of the medical record for patient #1 revealed Registered Nurse (RN) A documented on 12/3/09 at 10:00 PM, patient #1 had a Braden Scale Score of 14 [out of potential 24], and documented patient #1 was bedfast. On 12/4/10 at 2:57 AM, RN A documented "Patient noted to have dark black area of pressure sore on Left heel." On 12/5/09 at 7:30 AM, RN B documented in part, "... Pain: moaning and reports discomfort in [buttocks], bedpan removed and repositioned to the left sidelying position which [patient] reports is helping discomfort." "Wound Description ... dark red ring noted around buttocks both sides [sic] from bedpan that is removed. Turned to side off the buttocks..." Review of the Care Plan revealed RN A documented on 12/4/09 at 4:17 AM, "... Problem 3 Heels off bed..."

3. During an interview on 4/13/10 at 8:00 AM, RN C stated RN C assessed wounds on patient #1's legs, but did not assess patient #1's buttocks during the overnight shift for 12/4/09 to 12/5/09. RN C stated "I repositioned [the patient's] legs often, and [patient #1's] shoulders..." "[Patient #1] was not on a turn schedule... [Patient #1] was very difficult to move due to [patient #1's] size and [patient #1's] resistance [when staff attempted to move patient #1 in the bed]." "If the [patient] was on a 'turn schedule', it means I would have told the CNA at the start of the shift that we will be turning [patient #1] every 2 hours and set up time to [turn the patient] such as [on] even or odd hours."

4. During an interview on 4/13/10 at 4:00 PM, the Director of Nursing (DON) acknowledged the nursing staff failed to create an appropriate care plan for patient #1. The DON stated the care plan for patient #1 should have included nursing interventions such as turning the patient every 2 hours, and inspecting all of the patient's skin every shift for wounds, because patient #1's Braden Scale Score was 14 out of 24 and patient #1 already had pressure wounds on patient #1's heels. The DON also stated, "all of our patients are supposed to be turned every 2 hours..."