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MCLAREN MACOMB

1000 HARRINGTON ST

MOUNT CLEMENS, MI 48043

NURSING CARE PLAN

Tag No.: A0396

Based on medical record review, interview and policy review, the facility failed to ensure that nursing staff reassessed and evaluated patients' plan of care (POC) for 8 out of 20 patients (#2, #4, #13, #15, #16, #17, #18 and #19) resulting in the potential for ineffective care.
Findings include:

On 10/28/14 at approximately 0945, review of patient # 2's medical record revealed that the patient was admitted on 10/25/14 and failed to have an updated POC on 10/26/14.
On 10/28/14 at approximately 1000, review of patient #4's medical record revealed that the patient was admitted on 10/21/14 and failed to have an updated POC on 10/25/14 and 10/26/14.
On 10/28/14 at approximately 1400, review of patient #13's medical record revealed that the patient was admitted on 9/3/14 and failed to have a POC established until 9/5/14.
On 10/28/14 at approximately 1415, review of patient #15's medical record revealed that the patient was admitted on 9/22/14 and failed to have an updated POC on 9/24/14 and 9/26/14.
On 10/28/14 at approximately 1430, review of patient #16's medical record revealed that the patient was admitted on 9/21/14 and failed to have an updated POC on 9/24/14 and 9/29/14.
On 10/28/14 at approximately 1445, review of patient #17's medical record revealed that the patient was admitted on 9/30/14 and failed to have an updated POC on 10/5/14.
On 10/28/14 at approximately 1500, review of patient #18's medical record revealed that the patient was admitted on 10/3/14 and failed to have an updated POC on 10/5/14, 10/6/14 and 10/7/14.
On 10/28/14 at approximately 1530, review of patient #19's medical record revealed that the patient was admitted on 10/9/14 and failed to have an updated POC on 10/10/14, 10/11/14 and 10/12/14.
On 10/28/14 during review of the aforementioned medical records, staff B was in attendance and confirmed all findings.

On 10/29/14 at approximately 0930, review of the policy titled, "Nursing Electronic Documentation," revised July 2011, under the section titled, "Care Plan (initial)," states, "Starts upon admission." Further review of the same policy, under the section titled, "Care Plan Reassessment/Evaluation," states, "At least daily..."