HospitalInspections.org

Based on record review and interview, the facility failed to ensure nurses maintained individualized nursing care plans on three (3) of three (3) current patients on the 3rd floor medical surgical/ observation unit (patient IDs #2, 4 and 6).

Findings include:

Record review of patient's (ID#2) medical record revealed admit date of 8/9/2017 with no nursing care plan.

During an interview with patient (ID#2) on 8/14/2016 at 11:05, she stated she had been in the hospital for about 5 days. She had surgery on 8/10/17 to drain a painful abscess. She currently was receiving antibiotics and daily dressing changes by the nursing staff.

Record review of patient's (ID#4) medical record revealed admit date of 8/7/2017 with a vaginal abscess. The patient's history and physical stated past medical history of chronic laryngitis, thyroid nodules, liver cirrhosis, type 2 diabetes mellitus and chronic respiratory failure. Nursing care plan for patient ID# 4 stated Fall Risk.

During an interview with patient (ID# 4) on 8/14/2017, she stated that she has been in the hospital for about a week for an abscess that is now draining. She stated she has diabetes and receives oxygen through a nasal cannula. She is receiving antibiotics and sitz baths to help her infection.

Record review of patient's (ID # 6) medical record on 8/14/2017 revealed no nursing care plan and the patient was admitted 8/11/2017 with shortness of breath. She has a history of morbid obesity, congestive heart failure, chronic obstructive pulmonary disease and questionable obstructive sleep apnea.

Interview with director of quality (ID# 52) on 8/15/2017 at 1030 revealed that nursing care plans should be created during the initial assessment and updated as needed. Nursing care plans should be individualized based on patient needs, diagnosis and level of understanding.

Record review of facility policy titled Assessment Plan of Care dated 2012, pg 25 revealed the following information:
A Registered Nurse initiates the plan of care for the patient. A priority of needs list (known as the plan of care) is initiated on admissions by a Registered Nurse. Staff members base care decisions on the identified patient needs and prioritize care needs on the plan of care to occur in a time frame that meets the patient's needs.