HospitalInspections.org

Based on record review and interview the facility failed to ensure that nursing staff developed an individualized up to date nursing care plan for each patient in 11 of 11 (#1-#5, #20-#25) medical records; and assessments were not up to date for 9 of 15 medical records reviewed (#6, #7, #10, #11, #12, #13, #18, #19 and #25). Findings include:

On 5/29/2012 during medical record review it was revealed that patient's #2, #3, #5, #20, #21 and #25 care plans used were standardized care plans based on diagnosis. No individualized plan of care had been developed.

On 5/29/2012 at approximately 1600 during an in interview with Staff C and Staff D that the care plans used were not individualized. Staff C stated "We use the parts of the care plan that apply. If it does not apply they don't do that part. The care plans are picked based on diagnosis and identified problem areas."

On 5/29/2012 during medical record review of patients #6, #7, #10, #11 and #25 it was revealed that the document titled "24 Hour Medical Surgical Patient Care Summary" was lacking assessments and/or interventions for patients that may be a fall risk, using the Hendrich II Fall Risk Model. This finding was confirmed with staff B.

On 5/29/2012 during medical record review of patients #6, #7, #10, #11 and #25 it was revealed that the document titled "24 Hour Medical Surgical Patient Care Summary" was lacking assessments and/or interventions for the Hendrich II Fall Risk Model. This finding was confirmed with staff B.




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On 5/29/2012 during medical record review, it revealed that the documents used for patient's #1, #4 and #20-#24 care plans were standardized care plans based on diagnosis. No individualized plan of care had been developed.

During review of the medical record for patient #12 on 05/29/2012, revealed that the patient had been identified by the nursing staff on the 24 HR. Medical Surgical Patient Care Summary as a fall risk on 05/27/2012 by both the AM & PM nursing staff. Per the Hendrich II Fall Risk Model, a score >5 identified the patient as "High Risk" and the patient was scored as a 9 on both AM & PM shifts. The fall assessment lacked documentation of interventions being utilized to prevent a fall for the patient. On 05/28/2012, the fall assessment from the AM nurse was incomplete and the PM nurse again identified the patient as a high risk for falls with a score of 5. The fall assessment lacked documentation of interventions being utilized to prevent a fall for the patient.

During review of the medical record for patient #13 on 05/29/2012, revealed that the patient had been identified by the nursing staff on the 24 HR. Medical Surgical Patient Care Summary as a fall risk on 05/27/2012 both the AM &PM shift. Per the document, a score >5 identified the patient as "High Risk" and the patient was scored as a 6 on both shifts. The fall assessment lacked documentation of interventions being utilized to prevent a fall for the patient.

Review of documentation of fall assessment for patient #18, revealed that the patient was identified on 05/28/2012 as a "High Risk" for falls by both the AM & PM nursing staff. The fall assessment lacked documentation of interventions being utilized to prevent a fall for the patient.

Review of documentation of fall assessment for patient #19, revealed that on 05/28/2012 the patient was identified by both the AM & PM nursing staff as a fall risk. The fall assessment lacked documentation of interventions being utilized to prevent a fall for the patient.

During the record reviews with staff H on 5/28/2012 at approximately 1500, the findings were confirmed. Staff H stated "the staff are supposed to be documenting the interventions being used for the patient to prevent a fall." When asked if the fall interventions were documented any where else in the patient's medical record she stated "no."