HospitalInspections.org

Based on interview and record review, the facility failed to ensure that nursing staff developed and kept current a Nursing Care Plan for 1 out of 7 discharged patients (Patient #1).

Findings included:

TX00300551

Record review on 12/19/18 during time of survey of Patient #1's clinical records, revealed she was a 55 year old female admitted to facility on 10/8/18 and discharged 11/1/18. Her diagnoses were Schizoaffective disorder, bipolar type, Diabetes Mellitus, Obesity, Hypertension, Anemia, and Graves Disease.

Further record review failed to reveal any Nursing Care Plans addressing Diabetes Mellitus, Obesity, Hypertension, Anemia, or Graves Disease.


In an interview on 12/19/18 at 11:15 am with Quality Director, Staff #52, he stated that there should have been Nursing Care Plans to address the patients medical conditions, and not just her psychiatric conditions. The medical conditions including the diagnoses of Diabetes Mellitus, Obesity, Hypertension (high blood pressure), Anemia (general Anemia/lack of sufficient Red Blood Cells needed to distribute oxygen to the body's cells), and Graves Disease (an autoimmune enlargement of the thyroid gland with resultant alteration of thyroid function).

Record review of facility policy titled Master Treatment Plan, Patient Care Procedures" dated 12/21/14 stated: "I Policy: A. Every patient shall have an individualized, comprehensive Master Treatment Plan".