HospitalInspections.org

.
Based on document review, Medical Record review and interview, in three (3) of twelve (12) Medical Records, the Nursing Staff failed to consistently develop, and revise Nursing Care Plans specific to patients' co-morbidities and changes in Nursing Care needs.

This failure of developing and revising the Nursing Care Plans may lead to delays in and/or lack of treatment and care.

Findings include:

The facility Policy and Procedure titled "Knowledge-Based Charting (KBC) Documentation" last revised 11/28/18, stated the following: "the nursing responsibilities require a complete picture of the patient's individualized plan of care ... by documentation in the legal MR ... the Clinal Practice Guidelines (CPG) are part of the care planning process and are selected based on the clinical diagnosis and unique needs of the patient ... the Registered Nurse (RN) is responsible for ensuring the presence of a plan of care; an appropriate CPG selected and individualization."

The facility's Education Manual titled "Nursing KBC" dated 10/23/18, included instructions for the nursing staff to "add the CPG ... review the signs and symptoms of potential problems which are assessed throughout the shift ... [and] ... document these present signs and symptoms..."

Review of Patient #7's Medical Record identified the following information: This 53-year-old patient presented to the Emergency Room after an MVA (Motor Vehicle Accident). The patient was found to have sustained fractures of the maxillary sinus and right ulnar. The Physician documented that the patient was intoxicated with a past medical history of alcohol abuse. The CAT scan on admission revealed signs of Cirrhosis with Portal Hypertension. The patient was admitted to the SICU (Surgical Intensive Care Unit) in the afternoon on 03/05/19 and required intubation with mechanical ventilation on 03/06/19.

The Adult Plan of Care documented on 03/06/19 included CPGs for an Artificial Airway, Alcohol Withdrawal, Mechanical Ventilation and Fall Risk; but the CPGs for Orthopedic Fractures, Risk of Infection and Pressure Injury Risk were not added until 03/09/19.

The Nursing Progress Summary Note documented on 03/07/19 at 6:48PM revealed that the patient was extubated, and the Mechanical Ventilation CPG was discontinued, which removed the "Aspiration Precautions" Practice Guidelines from the Adult Assessment and Intervention (A&I) Flowsheet.

The Nursing Progress Summary Note on 03/08/19 at 7:37AM revealed that the patient was receiving NT (Nasal Tube) feeding and was having diarrhea. The patient was reintubated on 03/10/19 and the Mechanical Ventilation CPG was re-initiated. The patient had continued to receive NT feedings. The patient was removed from the ventilator and placed on a tracheostomy collar, and the Mechanical Ventilation CPG was discontinued on 03/20/19.

The Adult Plan of Care documented on 03/21/19 continued to include Artificial Airway, Fall Risk, Orthopedic Fractures, Risk of Infection and Pressure Injury, but the CPG for Enteral Nutrition (NT Feeding) was never added. As a result, the A&I Flowsheet documented on 03/21/19 did not include documentation that the Nursing Staff was monitoring the patient for aspiration or gastrointestinal complications related to the NT feedings.

Per interview of Staff J (Nurse Educator) on 03/22/19 at 10:30AM, Staff J stated "the nursing staff is instructed to choose the CPG which is related to the diagnosis or the patient's co-morbidities and add it to the Adult Plan of Care. The Plan of Care is individualized to the patient's condition and is added to when a problem arises. There is no limit, but they should be significant to the patient. The CPG then brings over Practice Guidelines to the Assessment and Intervention Flowsheet (A&I)."

The same lack of documentation of a developed and revised Nursing Care Plan was found in the Medical Records of Patients #6 and #11 for the review period of 03/19/19 to 03/22/19.

These findings were shared with the facility Administrators, Staff K (Nursing Director), Staff L (Nursing Director), and Staff M (Nurse Administrator) at 11:00AM on 03/22/19.