HospitalInspections.org

Based on record review and interview the facility failed to document patient and/or family member participation in the development and implementation of the plan of care. Citing 1 of 1 medical records reviewed. (Patient #1).

Review of patient medical record of 3/12/2013 revealed the following:
1. Review of patient #1 Plan of Care revealed no documentation of patient and/or family participation in plan of care process.

Interview with staff member #1 on 3/12/2013 confirmed with the electronic record, there was no place for the patient and/or family to document their involvement and understanding of the plan of care created for the patient.

Based on record review and interview the facility failed to ensure patient was turned every two hours to promote patient comfort and prevent complications from limited mobility. Citing 1 of 1 patient charts reviewed. (Patient #1).

Review of charts on 3/12/2013 at 2:00 pm in the facility revealed the following:

1. Patient #1 was admitted to room # 414 on 12/19/2012 at 8:30 pm from the emergency department. Documentation per nurses record reveal patient was position on back from 8:30 pm on 12/19/2012 until 6:37 am on 12/20/2012.
On 12/20/2012 patient positioning revealed:
a. 6:37 am - on back
b. 7:35 am- independent position (error- independent means patient can turn independently without assistance).
c. 9:30 am- still on back
d. 10:00 am- Turned to Left side
e. 12:00 noon- Turned to back
f. 2:00 pm- patient on back
g. 4:45 pm- patient on back.
h. 8:00 pm bath given
i. 10:00 pm- patient on back
On 12/21/2012 patient positioning revealed:
a. 12:00 midnight- patient on back.
b. 2:00 am- patient on back.
c. 4:00 am- patient turned to left side.
d. 6:00 am- patient on left side.
e. 8:00 am- bath given, linen change. Patient positioned on back.
f. 10:30 am- patient on left side.
g. 12:30 pm- patient turned to right side.
h. 2:30 pm- patient repositioned to back.
i. 4:07 pm- patient turned to left side.
j. 6:35 pm- patient on left side.
k. 8:00 pm- patient turned to right side.
i. 10:00 pm- patient on right side.
On 12/22/2012 patient positioning revealed:
a. 12:00 midnight- Patient positioned on back.
b. 2:00 am- patient turned to right side.
c. 4:17 am- patient turned to back.
d. 6:00 am- patient on back.
e. 7:45 am- patient on back.
f. 10:00 am- patient turned to left side
g. 11:00 am- bath given
h. 12:10 pm- patient turned to right side.
i. 2:10 pm- patient turned to back.

Review of nursing standard of care used by nursing staff at Paris Regional Medical Center per staff #3 on 3/13/2013 revealed the following:

Lippincott Williams & Wilkins- Pressure ulcer prevention on 3/13/2013 revealed the following:
As the name implies, pressure ulcers result when pressure- applied with great force for a short period or with less force for a long period- impairs circulation, depriving tissues of oxygen and other life-sustaining nutrients. This process damages skin and underlying structures. Untreated, resulting ischemic lesions can lead to serious infection.
Most pressure ulcers develop over bony prominence's, where frictional and shearing force combine with pressure to break down skin and underlying tissues. Persistent pressure on bony prominence's obstructs capillary blood flow, leading to tissue necrosis.
Implementation:
Turn and reposition patient every 1 to 2 hours, unless contraindicated. For patients with limited mobility, use a pressure-redistribution device, such as air, gel, or a 4" foam mattress overlay.
Post a turning schedule at the patient's bedside. Adapt position changes to his situation. Emphasize the importance of regular position changes to the patient and his family, and encourage their participation in the treatment and prevention of pressure ulcers by having them perform a position change correctly, after you have demonstrated how.

Interview with staff #6 on 3/13/13 confirmed the findings.

Based on record review and interview the facility failed to initiate the patient plan of care within 24 hours of admission. Citing 1 of 1 medical records reviewed. (Patient #1)

Review of medical records on 3/122013 revealed the following:
1. Plan of care for patient #1 was initiated on 2/21/2012 at 7:34 am. The patient was admitted to 4 East nursing unit on 2/18/2012 at 8:15 pm. The plan of care was not initiated within 24 hours of admission.

Review of Paris Regional Medical Center Policy and Procedures on 2/13/2013 revealed the following:

Section: Nursing/Patient Care
Policy: Planning and Providing Care
Effective Date: 4/2002
Revision Date: 6/2055

Purpose:
1.0 Planning and providing care, monitoring its results, modifying or completing care, and coordinating follow-up are fundamental activities required for the provision of patient care.
2.0 It is the policy of Paris Regional Medical Center (PRMC) to develop an individualized Plan of Care for each patient which involves an interdisciplinary, collaborative approach and reflects the patient's needs, severity of disease, condition, impairment or disability.
3.0 The patient's progress will be re-evaluated against the care goal and Plan of Care at least every 24 hours by a Registered Nurse.

Guideline:
Care planning is based on an assessment of the patient. Monitoring and determining the outcomes of care involve assessing and reassessing the patient's progress throughout treatment to determine care outcomes. Any modifications, including a decision to terminate care, are based on a reassessment and patient need. Coordinating follow-up care helps ensure that the patient's care needs are met or referred.
1.0 Care is planned to respond to each patient's unique needs (including age-specific needs), expectations, and characteristics with effective, efficient and individualized care.
2.0 Patient care, treatment, and rehabilitation are planned to ensure that they are appropriate to the patient's needs and severity of disease, condition, impairment or disability.
3.0 Settings and services required to meet patient care goals are identified, planned and provided if appropriate.
4.0 Care is planned and provided in an interdisciplinary, collaborative manner by qualified individuals.
4.1 Employees provide care according to their scope of practice, standards of practice, and hospital policies.
4.2 Some care may be carried out by the patient, family, or other caregivers following education.
5.0 Patient care procedures are performed in a manner that respects privacy.
6.0 Patient's progress is periodically evaluated against care goals and the plan of care and the plan or goals are revised as necessary.


Section: Nursing/Patient Care
Policy: Planning and Providing Care
Effective Date: 4/02
Revision Date: 6/2055

Definitions:
IPPOC- Interdisciplinary Patient Plan of Care

Procedures:
1.0 Assessment
1.1 Upon admission, a history and assessment will be obtained from the patient/family. From this process, actual and potential problems will be identified and prioritized.
1.2 Additional problem(s) will be identified by any discipline involved and added to the plan at any time during the patient's stay.
1.3 The Interdisciplinary Patient Needs Database tool is used to assess the initial needs for each patient.
1.4 Referrals will be made, using the Interdisciplinary Patient Needs Database, to disciplines that have been identified as needing to participate in the patient's care. The mix of disciplines involved will vary for each patient.
1.5 Each discipline uses the IPPOC to direct the care and to enhance communication of the plan and patient's progress between all member of the health care team.

2.0 Planning
2.1 The problems identified upon admission will be prioritized by an RN and used to develop an IPPOC within 24 hours of admission.

Interview with staff #1 on 3/13/2013 confirmed the findings.

Based on observation and interview the facility failed to ensure the blinds in patient rooms were functional and could be used to promote patient comfort. Citing 2 of 2 patient rooms observed. (Room # 411 and 414.)

While touring the facility on 3/12/2013 at 1:45 pm the following observation was made.
1. The window blinds in rooms 411 and 414 were non-functioning and had missing slats. The blinds were very difficult to adjust and could not be used to assure patient comfort.

Interview with staff #1 on 3/12/2013 at 1:45 pm confirmed the findings. Was advised that since moving to north campus in mid-October the facility needed some updating and repairs to be done.

Based on record review and interview the facility failed to document patient and/or family member participation in the development and implementation of the plan of care. Citing 1 of 1 medical records reviewed. (Patient #1).

Review of patient medical record of 3/12/2013 revealed the following:
1. Review of patient #1 Plan of Care revealed no documentation of patient and/or family participation in plan of care process.

Interview with staff member #1 on 3/12/2013 confirmed with the electronic record, there was no place for the patient and/or family to document their involvement and understanding of the plan of care created for the patient.

Based on record review and interview the facility failed to ensure patient was turned every two hours to promote patient comfort and prevent complications from limited mobility. Citing 1 of 1 patient charts reviewed. (Patient #1).

Review of charts on 3/12/2013 at 2:00 pm in the facility revealed the following:

1. Patient #1 was admitted to room # 414 on 12/19/2012 at 8:30 pm from the emergency department. Documentation per nurses record reveal patient was position on back from 8:30 pm on 12/19/2012 until 6:37 am on 12/20/2012.
On 12/20/2012 patient positioning revealed:
a. 6:37 am - on back
b. 7:35 am- independent position (error- independent means patient can turn independently without assistance).
c. 9:30 am- still on back
d. 10:00 am- Turned to Left side
e. 12:00 noon- Turned to back
f. 2:00 pm- patient on back
g. 4:45 pm- patient on back.
h. 8:00 pm bath given
i. 10:00 pm- patient on back
On 12/21/2012 patient positioning revealed:
a. 12:00 midnight- patient on back.
b. 2:00 am- patient on back.
c. 4:00 am- patient turned to left side.
d. 6:00 am- patient on left side.
e. 8:00 am- bath given, linen change. Patient positioned on back.
f. 10:30 am- patient on left side.
g. 12:30 pm- patient turned to right side.
h. 2:30 pm- patient repositioned to back.
i. 4:07 pm- patient turned to left side.
j. 6:35 pm- patient on left side.
k. 8:00 pm- patient turned to right side.
i. 10:00 pm- patient on right side.
On 12/22/2012 patient positioning revealed:
a. 12:00 midnight- Patient positioned on back.
b. 2:00 am- patient turned to right side.
c. 4:17 am- patient turned to back.
d. 6:00 am- patient on back.
e. 7:45 am- patient on back.
f. 10:00 am- patient turned to left side
g. 11:00 am- bath given
h. 12:10 pm- patient turned to right side.
i. 2:10 pm- patient turned to back.

Review of nursing standard of care used by nursing staff at Paris Regional Medical Center per staff #3 on 3/13/2013 revealed the following:

Lippincott Williams & Wilkins- Pressure ulcer prevention on 3/13/2013 revealed the following:
As the name implies, pressure ulcers result when pressure- applied with great force for a short period or with less force for a long period- impairs circulation, depriving tissues of oxygen and other life-sustaining nutrients. This process damages skin and underlying structures. Untreated, resulting ischemic lesions can lead to serious infection.
Most pressure ulcers develop over bony prominence's, where frictional and shearing force combine with pressure to break down skin and underlying tissues. Persistent pressure on bony prominence's obstructs capillary blood flow, leading to tissue necrosis.
Implementation:
Turn and reposition patient every 1 to 2 hours, unless contraindicated. For patients with limited mobility, use a pressure-redistribution device, such as air, gel, or a 4" foam mattress overlay.
Post a turning schedule at the patient's bedside. Adapt position changes to his situation. Emphasize the importance of regular position changes to the patient and his family, and encourage their participation in the treatment and prevention of pressure ulcers by having them perform a position change correctly, after you have demonstrated how.

Interview with staff #6 on 3/13/13 confirmed the findings.

Based on record review and interview the facility failed to initiate the patient plan of care within 24 hours of admission. Citing 1 of 1 medical records reviewed. (Patient #1)

Review of medical records on 3/122013 revealed the following:
1. Plan of care for patient #1 was initiated on 2/21/2012 at 7:34 am. The patient was admitted to 4 East nursing unit on 2/18/2012 at 8:15 pm. The plan of care was not initiated within 24 hours of admission.

Review of Paris Regional Medical Center Policy and Procedures on 2/13/2013 revealed the following:

Section: Nursing/Patient Care
Policy: Planning and Providing Care
Effective Date: 4/2002
Revision Date: 6/2055

Purpose:
1.0 Planning and providing care, monitoring its results, modifying or completing care, and coordinating follow-up are fundamental activities required for the provision of patient care.
2.0 It is the policy of Paris Regional Medical Center (PRMC) to develop an individualized Plan of Care for each patient which involves an interdisciplinary, collaborative approach and reflects the patient's needs, severity of disease, condition, impairment or disability.
3.0 The patient's progress will be re-evaluated against the care goal and Plan of Care at least every 24 hours by a Registered Nurse.

Guideline:
Care planning is based on an assessment of the patient. Monitoring and determining the outcomes of care involve assessing and reassessing the patient's progress throughout treatment to determine care outcomes. Any modifications, including a decision to terminate care, are based on a reassessment and patient need. Coordinating follow-up care helps ensure that the patient's care needs are met or referred.
1.0 Care is planned to respond to each patient's unique needs (including age-specific needs), expectations, and characteristics with effective, efficient and individualized care.
2.0 Patient care, treatment, and rehabilitation are planned to ensure that they are appropriate to the patient's needs and severity of disease, condition, impairment or disability.
3.0 Settings and services required to meet patient care goals are identified, planned and provided if appropriate.
4.0 Care is planned and provided in an interdisciplinary, collaborative manner by qualified individuals.
4.1 Employees provide care according to their scope of practice, standards of practice, and hospital policies.
4.2 Some care may be carried out by the patient, family, or other caregivers following education.
5.0 Patient care procedures are performed in a manner that respects privacy.
6.0 Patient's progress is periodically evaluated against care goals and the plan of care and the plan or goals are revised as necessary.


Section: Nursing/Patient Care
Policy: Planning and Providing Care
Effective Date: 4/02
Revision Date: 6/2055

Definitions:
IPPOC- Interdisciplinary Patient Plan of Care

Procedures:
1.0 Assessment
1.1 Upon admission, a history and assessment will be obtained from the patient/family. From this process, actual and potential problems will be identified and prioritized.
1.2 Additional problem(s) will be identified by any discipline involved and added to the plan at any time during the patient's stay.
1.3 The Interdisciplinary Patient Needs Database tool is used to assess the initial needs for each patient.
1.4 Referrals will be made, using the Interdisciplinary Patient Needs Database, to disciplines that have been identified as needing to participate in the patient's care. The mix of disciplines involved will vary for each patient.
1.5 Each discipline uses the IPPOC to direct the care and to enhance communication of the plan and patient's progress between all member of the health care team.

2.0 Planning
2.1 The problems identified upon admission will be prioritized by an RN and used to develop an IPPOC within 24 hours of admission.

Interview with staff #1 on 3/13/2013 confirmed the findings.

Based on observation and interview the facility failed to ensure the blinds in patient rooms were functional and could be used to promote patient comfort. Citing 2 of 2 patient rooms observed. (Room # 411 and 414.)

While touring the facility on 3/12/2013 at 1:45 pm the following observation was made.
1. The window blinds in rooms 411 and 414 were non-functioning and had missing slats. The blinds were very difficult to adjust and could not be used to assure patient comfort.

Interview with staff #1 on 3/12/2013 at 1:45 pm confirmed the findings. Was advised that since moving to north campus in mid-October the facility needed some updating and repairs to be done.