HospitalInspections.org

Based on record review and interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient, in that, 2 of 8 patient's (Patient #1 and #2) did not document patient specific care for the patient's current issues.

Findings included

1) Patient #1's 11/19/18 through 11/21/18 record reflected a skin assessment on 11/19/18 documenting left forearm burns. The physician documented the burns in his 11/19/18 Psychiatric Evaluation Note.

There is no documentation of further assessment, wound care referral, orders, wound care, or dressing changes.

During an interview and record review on 6/17/19 at 3:30 PM, Personnel #3 navigated the electronic record. Personnel #3 confirmed there is no documentation of further assessment, wound care referral, orders, wound care, or dressing changes.

2) 2) Patient #2's 6/14/19 admission record reflected the patient complained of 6 of 10 constant, aching left hip and shoulder pain at 21:00 PM. Patient #2's 6/15/19 Admission History and Physical reflected, "Arthritis...hip pain with walking...left shoulder pain..."

There was no pain medication given.

During an interview and record review on 6/17/19 at 3:30 PM, Personnel #3 navigated the electronic record. Personnel #3 confirmed the above findings.

Based on record review and interview, the facility failed to ensure the nursing staff developed, and kept current, a nursing care plan for each patient, in that, 2 of 8 patient's (Patient #1 and #2) did not document patient specific care plan for the patient's current issues.

Findings included

1) Patient #1's 11/19/18 through 11/21/18 record reflected a skin assessment on 11/19/18 documenting left forearm burns. Patient #1's 11/19/18 Psychiatric Evaluation Note documented the burns.

There is no documentation of a burn/wound care plan.

During an interview and record review on 6/17/19 at 3:30 PM, Personnel #3 navigated the electronic record. Personnel #3 confirmed there is no documentation of a burn/wound care plan.

2) Patient #2's 6/14/19 admission record reflected the patient complained of 6 of 10 constant, aching left hip and shoulder pain at 21:00 PM. There was no pain medication given. Patient #2's 6/15/19 Admission History and Physical reflected, "Arthritis...hip pain with walking...left shoulder pain..."

There is no documentation of a pain care plan.

During an interview and record review on 6/17/19 at 3:30 PM, Personnel #3 navigated the electronic record. Personnel #3 confirmed there is no documentation of a pain care plan.