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Based on observation, interview, and record review, the facility failed to develop nursing care plans for 3 patients (Patients 1, 16, and 29) to address Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2, a viral infection). This failure had the potential to result in substandard quality of care for Patients 1, 16, and 29.

Findings:

1. On 8/20/20 at 10:34 AM, an initial tour was conducted in Cardiovascular Acute Unit with the Director of Heart Institute (DOHI). During the observation, Patient 1's room door was closed and a sign was posted outside the door indicating, "Combined droplet and eye protection."

During a concurrent interview with the DOHI, DOHI stated Patient 1 required isolation precautions due to their SARS-CoV-2 infection status. DOHI stated all staff were required to wear personal protective equipment (PPE- any device or appliance designed to be worn or held by an individual for protection against one or more health and safety hazards) when entering the room and providing care.

During a review of the clinical record for Patient 1, the face sheet indicated Patient 1 was admitted on 8/11/20, with diagnoses that included failure to thrive (decelerated physical growth associated with abnormal growth and development).

During a review of the SARS-CoV-2 laboratory result, dated 8/11/20 at 6:27 PM, indicated Patient 1 was positive for SARS-CoV-2.

During a review of Patient 1's medical record failed to show documented evidence that a nursing care plan was developed and kept current to address nursing interventions and patient goals for Patient 1's current health status related to SARS-CoV-2 infection.

During an interview on 8/24/20 at 2:20 PM, with the Unit Manager (UM 2), UM 2 was unable to locate a nursing care plan for Patient 1's SARS-CoV-2 infection status. UM 2 stated the registered nurses should have initiated the care plan within twenty-four hours upon admission for Patient 1 and updated the care plan every 12 hours.


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2. On 8/20/20 at 10:40 AM to 12:20 PM, an initial tour was conducted in Unit 3 with Registered Nurse 2 (RN 2). During the observation, Patient 16's room door was closed and a sign was posted outside the door indicating "Combined droplet and eye protection."

During a concurrent interview with RN 2, RN 2 stated Patient 16 required isolation precautions due to their SARS-CoV-2 infection status. RN 2 stated all staff were required to wear PPE when entering the room and providing care.

During a review of the medical record for Patient 16's face sheet, indicated Patient 16 was admitted on 8/8/20, with diagnoses that included possible leukemia (cancer of the blood).

During a review of the History and Physical, dated 8/8/20, indicated Patient 16 was positive for SARS-CoV-2 infection on 8/8/20.

During a review of Patient 16's medical record failed to show documented evidence that a nursing care plan was developed and kept current to address nursing interventions and patient goals for Patient 16's current health status related to SARS-CoV-2 infection.

3. On 8/21/20 at 9:05 AM, an initial tour was conducted in Unit 3 with Registered Nurse 3 (RN 3). During the observation, Patient 29's room door was closed and a sign was posted outside the door indicating "Combined droplet and eye protection."

During a concurrent interview with RN 3, RN 3 stated Patient 29 required isolation precautions due to SARS-CoV-2 infection status. RN 3 stated all staff were required to wear PPE when entering the room and providing care.

During a review of the medical record for Patient 29's face sheet, indicated Patient 29 was admitted on 8/21/20, with diagnoses that included acute lymphoblastic leukemia (a type of cancer of the blood and bone marrow that affects white blood cells).

During a review of the History and Physical, dated 8/21/20, indicated Patient 29 was positive for SARS-CoV-2 infection.

During a review of Patient 29's medical record failed to show documented evidence that a nursing care plan was developed and kept current to address nursing interventions and patient goals for Patient 29's current health status related to SARS-CoV-2 infection.

During an interview with Unit Manager 3 (UM 3) on 8/24/20 at 11:23 AM, UM 3 stated registered nurses assigned to care for each patient were responsible for initiating, updating and revising care plans. UM 3 stated the registered nurses did not develop and keep current nursing care plans to address Patient 16 and 29's current health status related to SARS-CoV-2.

A review of the facility's policy and procedure titled, "Interdisciplinary Care Planning-General," dated 10/4/18, included the following:.."All patients admitted to the hospital will have a plan of care with short and long term goals that identified current problems, goal, interventions and outcome reflecting individualized actions in the care of the patients. All sections will be initiated within 24 hours. Maintenance of the sections shall be performed on a daily basis..."