HospitalInspections.org

Based on MR review, review of P&P and interview with staff, in 4 of 4 MRs requiring a CP (1, 2, 3 and 4) out of a total of 5 MRs reviewed, the facility failed to ensure the CP is individualized to Pt needs, includes measurable goals and interventions that are applicable to the Pts. This deficiency directly affects 4 Pts treated at the facility and potentially affects all Pts treated at the facility.

Findings include:

Review on 8/28/13 in the PM of facility policy titled Patient Care Planning, dated 11/12, states under Implementation II.B.2 "Clinical Practice Guidelines (CPG)-Care Plan Problems and/or Needs-these can be based on a medical diagnosis, related symptom or human response relevant to the hospitalization....3. Goals-May be patient specific, education related, and/or designated to prevent and manage complications. 4. Interventions-Used to assist the patient and/or family in progressing toward their goals and achieving therapeutic outcomes."

Per interview with CCO A on 8/27/13 during MR review between 12:30 PM and 2:20 PM, CCO A acknowledged CPs are not always individualized, including goals that are not measurable, and interventions appropriate to the Pt.

Pt #1's MR review on 8/27/13 at 12:30 PM revealed Pt #1 was admitted on 8/24/13 for a primary diagnosis of Hyponatremia (low sodium in blood). There are 5 Nursing CP problems including 1) Physical Mobility, Impaired with a goal of "Enhanced Mobility Skills, Patient will demonstrate the desired outcomes" and goal "Enhanced Functionality Ability, Patient will demonstrate the desired outcomes." 2) Infection, Risk/Actual with a goal of "Infection Prevention/Resolution/Control, Patient will demonstrate the desired outcomes." 3) Coping, Compromised Family with a goal Effective Family Coping, Patient will demonstrate desired outcomes." These goals are not measurable to determine Pt meeting the goals at or prior to discharge. The interventions listed for the problems included all possible interventions and are not specific to the Pt needs. This is confirmed in interview with CCO A and Dir C during MR review.

Pt #2's MR review on 8/27/13 at 12:55 PM revealed Pt #2 was admitted on 8/25/13 for a primary diagnosis of Paraparises (partial paralysis) and breast cancer. There are 4 Nursing CP problems including 1) Pressure Ulcer Risk with a goal of "Skin Integrity, Patient will demonstrate the desired outcomes" and goal "Enhanced Functionality Ability, Patient will demonstrate the desired outcomes." 2) Urine Elimination, Impaired with a goals "Effective Urinary Elimination, Patient will demonstrate desired outcomes"; "Effective Containment of Urine, Patient will demonstrate the desired out comes"; "Reduced Incontinence Episodes, Patient will demonstrate the desired out comes". These goals are not measurable to determine Pt meeting the goals at or prior to discharge. Pt #2 reported pain levels of 5 to 10 out of 10 requiring multiple doses of narcotics between 8/25/13 and MR review on 8/27/13. There is no CP for Pain Management. The interventions listed for the problems included all possible interventions and are not specific to the Pt needs. This is confirmed in interview with CCO A and Dir C during MR review.

Pt #3's MR review on 8/27/13 at 1:35 PM revealed Pt #3 was admitted on 8/23/13 for a primary diagnosis of Appendicitis. There are 3 Nursing CP problems including Appendicitis/Appendectomy with a goal "Signs and symptoms of listed potential problems will be absent or manageable." Pt #3 has received multiple doses of pain medication since admission, there is no CP for Pain Management. These goals are not measurable to determine Pt meeting the goals at or prior to discharge. The interventions listed for the problems included all possible interventions and are not specific to the Pt needs. This is confirmed in interview with CCO A and Dir C during MR review.

Pt #4's MR review on 8/27/13 at 2:10 PM revealed Pt #4 was admitted on 8/23/13 for a primary diagnosis of confusion and weakness. There are 4 Nursing CP problems including 1) Pressure Ulcer Risk with a goal of "Skin Integrity, Patient will demonstrate the desired outcomes" and goal "Enhanced Functionality Ability, Patient will demonstrate the desired outcomes." 2) Confusion, Chronic/Acute with a goal "Cognitive Ability, Patient will demonstrate desired outcomes"; "Functional Ability, Patient will demonstrate the desired out comes" and "Restorative Sleep/Rest, Patient will demonstrate the desired out comes". These goals are not measurable to determine Pt meeting the goals at or prior to discharge. The interventions listed for the problems included all possible interventions and are not specific to the Pt needs. This is confirmed in interview with CCO A and Dir C during MR review.

Based on MR review, review of P&P and interview with staff, in 1 of 1 MR requiring anesthesia services (3), the facility failed to ensure the post-anesthesia note is comprehensive including:Cardiopulmonary status, Level of consciousness, observations, follow up and/or complications. This deficiency potentially affects all surgical Pts treated at the facility.

Findings include:

Review on 8/27/13 in the PM of facility policy titled Standard of Anesthesia Practice, n.d., states under #6 "Complete, in an accurate and timely manner, all documentation of pertinent information on the on the patient's medical record. Per interview with CCO A on 8/27/13 at approximately 4:15 PM the policy does not address specific data to be documented.

Pt #3's MR review on 8/27/13 at 1:35 PM revealed Pt #3 had an appendectomy on 8/23/13 under General Anesthesia. The Post Anesthetic Note dated 8/24/13 at 1:00 AM has yes or no check boxes for N/V (nausea/vomiting), Recall and Parethesia from positioning. There is a line drawn through the "no" boxes. This does not constitute a complete post anesthesia note that includes cardiopulmonary status (set of vital signs), level of consciousness (awake, alert, lethargic, etc.), observation, follow up and/or complications. This is confirmed in interview with COO A and Dir C during the MR review, acknowledging there is no specific information related to recovery from anesthesia.