HospitalInspections.org

Based on record reviews, staff interviews and review of facility policy and procedure, the facility failed to ensure that nursing staff developed/revised a plan of care to meet the patients needs for 3 of 31 sampled patients (Patient 17, 20 and 23). The total sample size was 31. Facility inpatient census was 1.

Findings are:

A. Review of the medical record for Patient (Pt) 17 revealed an admission date of 1/19/17 for the chief complaint of an elevated temperature of 102-103 degrees and Russell Silver Syndrome (A genetic disease that affects the baby's birth weight and development.). Patient 17's plan of care identified "Acute Rise of Fever". During Pt 17's stay it was identified that Pt 17 was malnourished due to the current illness. A nasogastric tube (NG-a tube inserted through the nose and ends in the stomach to provide nutritious liquid feedings.) was inserted on 1/20/17 at 1537 (3:57 PM). Pt 17 was to have an oral diet, supplemented with Pediasure 4 ounces every 3-4 hours.

Review of Pt 17's plan of care lacked revision related to the need of the placement and management of the NG.

An interview with Advanced Practice Registered Nurse (APRN) B on 6/27/17 at 10:09 AM verified Pt 17's plan of care lacked a problem for malnutrition and the insertion of the NG tube.

B. Review of the medical record for Patient 23 revealed an admission date of 3/14/17 for the chief complaint of fever for 4 days and cough. Pt 23's plan of care identified "Pyrexia (fever) of unknown origin". During Pt 23's stay it was identified that Pt 23 was unimmunized and had a critical low white blood count (WBC-cells in the body that help fight infection.) of 2.7 (normal range 3.4-9.9) Pt 23 was placed in protective isolation due to the potential for the patient's immune system to fight off infections the pt may come in contact with.

Review of Pt 23's plan of care lacked revision related to the need of protective isolation due to critically low WBC's and unimmunized status.

An interview with APRN B on 6/27/17 at 4:00 PM verified the plan of care for Pt 23 lacked a problem for the need of protective isolation, the critically low WBC's and the unimmunized status. APRN B stated, "I have been doing chart reviews for 1.5 weeks and unfortunately this problem does not surprise me."

C. Review of the medical record for Patient 45 revealed an admission date of 4/21/17 for the chief complaint of cellulitis (infection of the skin). Pt 45's plan of care identified "Acute rise of fever". During Pt 45's stay it was identified that Pt 45 had an infection of the tissue by the right ear and was treated for the infection while at the hospital.

Review of Pt 45's plan of care lacked revision related to the infection of the tissue by the right ear and treatment for that infection.

An interview with APRN B on 6/27/17 at 2:28 PM verified the plan of care for Pt 45 lacked a problem for identification and treatment of the tissue infection by the right ear.

D. Review of the facility policy titled "Nursing Process and Clinical Practice Guideline for Documentation" effective date 4/15/14 with last review date 6/15/17, revealed:
-Purpose: To guide the nursing care provider on care plan and documentation systems as a part of the patient's permanent record.
-Planning/Goal Setting: "Review the plan of care for appropriateness.; Individualize the plan of care by focusing on specific factors contributing to the problem or subjective/objective data, if appropriate; and apply priority level to each problem list/plan of care item: low, moderate, or high."
-Evaluation: "Problem list/plan of care will be revised as necessary."

Based on record reviews, staff interviews and review of facility policy and procedure, the facility failed to ensure that 1 of 2 patients (Patient 17) had documentation in their medical record showing that the patient/family received a list of Home Health Care agencies to choose from prior to discharge and failed to have documentation of approval of the Discharge Plan in the patient's medical record. The total sample size was 31. Facility inpatient census was 1.

Findings are:

A. Review of the medical record for Patient (Pt) 17 revealed an admission date of 1/19/17 for the chief complaint of an elevated temperature of 102-103 degrees and Russell Silver Syndrome (A genetic disease that affects the baby's birth weight and development.). Patient 17's plan of care identified "Acute Rise of Fever". During Pt 17's stay it was identified that Pt 17 was malnourished due to the current illness. A nasogastric tube (NG-a tube inserted through the nose and ends in the stomach to provide nutritious liquid feedings.) was inserted on 1/20/17 at 1537 (3:57 PM). Pt 17 was to have an oral diet, supplemented with Pediasure 4 ounces every 3-4 hours.

Pt 17's record identified that the patient was dismissed on 1/22/17 to home. A physician order dated 1/20/17 identified "Home Health Consult", under the comments of the order it stated, "(NAME OF A HOME HEALTH COMPANY) for NG supplies and teaching. Weekly weight checks for 4 weeks."

The Nurses Notes dated 1/20/17 at 15:10 identified "(NAME OF A HOME HEALTH COMPANY) notified of HHC (home health care) orders, faxed to office. Informed RN to have patient's RN call (NAME OF HOME HEALTH COMPANY) when discharging."

Review of the Nursing Admission Assessment completed on 1/19/17 did not identify Pt 17 using a HHC agency prior to admission.

Review of Pt 17's medical record lacked an offer of a list of HHC agencies to pick from for services upon discharge. Pt 17's medical record lacked an acknowledgment and agreement of the Discharge Plan regarding post hospital care needed.

An interview on 6/28/17 from 9:55 AM to 11:00 AM with the Quality Director, Medical Director, Nurse Infomatics specialist, Director of Nurses, APRN, Director of the Inpatient Medical Unit, Charge Nurse and Social Worker related to Patient 17's record was conducted. The Quality Director verified that Pt 17's medical record lacked the acknowledgement and agreement of the Discharge Plan. The Quality Director identified that the patient received dismissal instructions that identified the HHC agency following Pt 17 upon discharge. The Social Worker identified that there was no documentation of a list of Home Health Agencies provided to the patient.

Review of the Nursing Process and Clinical Practice Guideline for Documentation with an effective date of 4/15/14 with last review date of 6/15/17 revealed:
-Purpose: To guide the nursing care provider on care plan and documentation systems as a part of the patient's permanent record.
-Actions/Intervention/Implementation:"Coordination of discharge care needs and discharge teaching. refer to the policies: Discharge, Inpatient."