HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of 11 patients. Based on document review and staff interview the CAH failed to ensure nursing staff completed plans of care for 11 of 20 patient records reviewed (patient #s 3, 4, 5, 6, 8, 9, 10, 11, 13, 15 and 18).

Findings include:

- Patient # 3 ' s medical record reviewed on 2/14/12 revealed an admission date of 2/12/12 with a diagnosis of hyponatremia (low salt levels in blood). Review of the medical record revealed staff identified problems on the patient ' s plan of care. The plan of care form lacked evidence of establish patient goals and interventions to treat the identified problems.

- Patient # 4 ' s medical record reviewed on 2/14/12 revealed an admission date of 2/13/12 to rule out pneumonia. Review of the medical record revealed staff identified problems on the patient ' s plan of care. The plan of care form lacked evidence of establish patient goals and interventions to treat the identified problems.

- Patient # 5 ' s medical record reviewed on 2/14/12 revealed an admission date of 2/10/12 with a diagnoses of significant edema and chronic obstructive pulmonary disease (COPD). Review of the medical record revealed staff identified problems on the patient ' s plan of care. The plan of care form lacked evidence of establish patient goals and interventions to treat the identified problems.

- Administrative staff B interviewed on 2/14/12 at 1:00pm acknowledged the staff failed to complete the plan of care for the patients.

- Failure to complete patient plans of care also affected patient #s 6, 8, 9, 10, 11, 13, 15 and 18.