HospitalInspections.org

Based on clinical record review and interview, it was determined for seven of seven (#1-#7) current inpatients on the Critical Care Unit, the nursing care plan did not have measurable goals with specific interventions to deliver patient care. The failed practice prevented the implementation of an effective plan of care. The failed practice has the potential to affect all patients admitted to the Critical Care Unit. The findings were:

A. Patient #1: Review of the plan of care revealed the goal and interventions for "Fluid Volume Deficit" were not measurable as follows:
1) Goals were:
Understands adequate fluid intake. There was no indication how much fluid the patient should consume with a 24 hour period to be considered adequate.
Evidence no significant weight fluctuations. There was no numeric indicator which would prompt the staff to know when a significant fluctuation had occurred.
Maintains optimal lab (laboratory) values. There was no identification of which lab values should be monitored and their normal limits.
2) Evidences of balanced intake and output.
Interventions were:
Monitor nasogastric tube drainage. There was no evidence how often the monitoring was to take place.
Lavage via NG tube. There was no evidence how often the lavage was to take place and the volume of normal saline to use.
3) There was no intervention on how often fluid was to be offered or consumed per shift or day; there was no intervention of monitoring and recording intake to assure hydration and a balance intake and output; there was no intervention regarding lab values; and and there was no intervention on monitoring the weight to assure there was no significant weight fluctuation.
The remaining five identified problems had no measurable goals with specific interventions identified.
B. Patient #2: Review of the plan of care for "Decreased Cardiac Output" revealed the goals were not measurable and interventions were not specific as follows:
1) Goals were:
Achieve hemodynamic stability.
Maintains vital signs WNL (within normal limits).
Maintains balanced intake and output.
Exhibits usual mental status. There was no indication of what the patient's normal mental status was to identify when a change had occurred.
Evidences no significant weight fluctuations. There was no numeric indicator which would prompt the staff to know when a significant fluctuation had occurred.
2) Interventions were:
Hemodynamic monitoring. There was no evidence how often the monitoring was to occur.
There was no intervention on how often fluid was to be offered or consumed per shift or day; there was no intervention of monitoring and recording intake to assure hydration and a balance intake and output; there was no intervention regarding lab values; and and there was no intervention on monitoring the weight to assure there was no significant weight fluctuation
The remaining five identified problems had no measurable goals with specific interventions identified.
C. Patient #3: Review of the plan of care for "Altered Nutritional Status" revealed the goals were not measurable and interventions were not specific as follows:
1) Goals were:
Maintains adequate caloric intake. There was no numeric value listed to identify the caloric intake necessary to consume to maintain or improve their nutritional status.
Maintain weight within 10% of the IBW (ideal body weight). There was no indication of what the patient's IBW was.
2) The only intervention was "Nutritional Assessment (Nursing)." There was no intervention to weigh the patient to assure the weight was maintained within 10% of the IBW. There was no intervention to address the caloric intake.
The remaining seven identified problems had no measurable goals with specific interventions identified.
D. Patient #4: Review of the plan of care for "Infection" revealed there were goals were not measurable and interventions were not specific:
1) Goals were:
Maintain vital signs within normal limits. There was no indication what the patient's normal limits were to judge if a deviation had occurred.
Maintain optimal lab values. There was no indication which lab values would be required to monitor related to the identified problem.
2) Interventions were:
Assess hydration status. There was no identification what measures would be used to assure the patients hydration status was met.
Implement appropriate precautions. There was no indication what precautions were necessary.
Teach s/s (signs and symptoms) of infection. There was no indication of where the infection was located or the type to assure the correct s/s were given. The list on plan of care included redness, swelling, increased pain or purulent drainage at: incisions, injured sites, exit sites of tubes, drains, catheters; elevated temperature-no evidence of numeric value constituted an temperature or elevation of the patients baseline; change in color of respiratory secretions; and change in appearance of urine.
The remaining three identified problems had no measurable goals with specific interventions identified.
E. Patient #5: Review of the plan of care for "Impaired Gas Exchange" revealed the goals were not measurable and interventions were not specific as follows:
1) Goals were:
Maintain optimal gas exchange-maintains baseline ABGs (arterial blood gases-evidences usual mental status-evidences usual skin color). There was no evidence of what the baseline ABGs were, what the usual mental status was and what the usual skin color was to determine when a change had occurred.
Maintain optimal oxygenation. There was no evidence of what was optimal oxygenation.
2) Interventions were:
Assess level of consciousness. There was no indication how often the assessment was to be performed.
Monitor ABG values. There was no indication how often the ABG was to be performed.
Monitor for s/s (sign/symptoms) hypoxemia/hypercapnia. There was no indication how often the monitoring was to be performed.
Monitor pulse oximetry. There was no indication how often the monitoring was to be performed.
The remaining 13 identified problems had no measurable goals with specific interventions identified.
F. Patient #6: Review of the plan of care for "Fluid Volume Deficit" revealed the goals were not measurable and interventions were not specific as follows:
1) Goal was maintain fluid and electrolyte balance (maintain vital signs WNL, maintain urine output greater than (>) 30 ml/hr (milliliters/hour), evidence of normal skin turgor, maintain urine specific gravity WNL and evidence of no significant weight fluctuations). There was no evidence of what the patients normal vital sign status was; there was no indication of what WNL was for a specific gravity; and there was no numeric value to determine what a significant weight fluctuation was.
2) Interventions were:
Assess hydration status. There was no evidence how often the hydration status would be assessed. There was no goal on how much fluid should be consumed to maintain hydration status.
Monitor s/s fluid/electrolyte imbalance (poor skin turgor, weight gain/loss, elevated temperature, tachycardia, hypotension, imbalance between intake and output, confusion, irritability, increasing lethargy, cardiac arrhythmias, edema and neuromuscular changes). There was no indication how often this would be monitored.
There was no intervention to include how often the patient would be weighed to identify a weight loss or gain; there was no intervention on how they were going to monitor a urine output of > 30 ml/hr; and there was no intervention on how often a specific gravity would be done to determine if it was WNL.
The remaining five identified problems had no measurable goals with specific interventions identified.
G. Patient #7: Review of the plan of care for "Activity Intolerance" revealed the goals were not measurable and interventions were not specific as follows:
1) Goal was maintain/increase activity levels (helps perform self care activities, maintain maximum range of motion and maintains vital signs WNL during activity). There was no evidence at what level the patient current at and at what level did they want to increase the level to; what was the maximum level for range of motion; and what was WNL for vital signs during activity.
2) Interventions were:
Alternate activity/rest periods.
Teach: Energy Conservation Methods
There was no evidence how the above interventions were going to increase the patients activity level; there was no evidence what activities were going to be provided to maximize the patient's range of motion.
The remaining six identified problems had no measurable goals with specific interventions identified.

Based on observation and interview, it was determined the safety of patients was not protected in that one (by Treatment Room #5) of three designated emergency exits for the Emergency Department (ED) was blocked by patient care equipment. The failed practice did not assure patients, visitors and staff could quickly exit the building in the event of an emergency. The findings were:

During observation of the ED on 09/26/12 at 1349, there was an exit to the outside of the building by Treatment Room #5. There was a battery operated emergency light above the door and there was an emergency pull box to the left of the door. In the short corridor leading to the exit, there was a stretcher, lamp, step stool, monitor and two privacy curtains. At the time of the observation the ED Director was asked why those items were in the corridor; she stated sometimes it was used as an overflow area when the ED was full. The ED Director was asked if the exit was designated as an emergency exit to which she said "yes". The ED Director stated the emergency exits for the ED was the ambulance entrance, entrance into the waiting room area and the exit at Treatment Room #5.