HospitalInspections.org

A. Based on document review, medical record review and interviews it was revealed the hospital failed to update the treatment plans for two (2) of thirty (30) patients (patients #1 and 2) who had a change in condition requiring new orders. This failure to update the treatment plan has the potential to affect the care of all patients who have a change in condition requiring new orders.

Findings include:

1. A review of the hospital policy entitled 'Patient Sexual Behavior,' last revised 12/26/18, revealed in part: "When deemed a clinical issue, the patient's treatment plan should address goals, objectives and interventions for prevention of inappropriate sexual behaviors ..."

2. A review of the hospital policy entitled 'Precautions Levels and Record,' last revised 10/9/18, revealed in part: "Close Constant Observation is defined as continual observation of patients (who have been identified as risks to themselves or others) ...This intervention will be included in the treatment plan if this level of observation is due to behavioral issues that concern the safety of the patient or others ..."

3. A review of the hospital policy entitled 'Levels of Observation,' last revised 4/19/19, revealed in part: "A medical provider may order specific instructions for special monitoring based on an assessed need of a patient. The instructions shall be entered into the patient's medical record and documentation of these instructions shall be written into the patient's treatment plan..."

4. A review of the hospital policy entitled 'Abuse and Neglect Policy,' last revised 1/28/16, revealed in part: "Patient to Patient Abuse Process ...Therapist will update treatment plan with new interventions ..."

5. A review of patient #1's medical record revealed documentation of inappropriate sexual behavior occurring on 11/12/19 at approximately 8:45 p.m. and there was no update made to the treatment plan.

6. A review of patient #2's medical record revealed documentation of inappropriate sexual behavior occurring on 11/11/19 at approximately 12:20 p.m. and there was no update made to the treatment plan.

7. A review of patient #2's medical record revealed the patent was ordered close constant observation and special monitoring on 11/13/19 and there was no update made to the treatment plan.

8. An interview was conducted with the Director of Therapy Services on 11/20/19 at approximately 9:00 a.m. and she concurred with the above findings.

B. Based on document review, medical record review and interviews it was revealed the hospital failed to update the nursing care plan for one (1) of thirty (30) patients (patient #1) after a condition change and new order for "No Roommate" was received. Failure to update the nursing care plan has the potential to affect the care of all patients who have a condition change and new orders from the physician.

Findings include:

1. A review of the policy entitled 'Nursing Care Plan,' date of approval 9/18/18, revealed in part: "Updates to care plans: Are to be updated as the patient's condition changes, new or changed orders received ..."

2. A review of patient #1's medical record revealed the patient entered another patient's room and touched the other patient. After this incident an order was entered on patient #1's medical record for "No Roommate" and the nursing care plan was not updated with the new order.

3. An interview was conducted on 11/20/19 at approximately 9:40 a.m. with the Director of Patient Care Services and she concurred with the above findings.