HospitalInspections.org

Based on review of documents, medical records and staff interview, it was determined the facility failed to ensure nursing care plans are developed and kept current for each patient. This practice impacted two (2) of three (3) inpatient records reviewed for care plans (patients #11 and #12). This failure has the potential to negatively affect all patients by not accurately identifying and documenting actual and potential patient conditions which is crucial to developing appropriate nursing interventions and evaluating patient's ongoing needs, responses and progress.

Findings include:

1. The current Nursing Care Plan Policy, dated 10/89, revised 12/99, states that "care plans will reflect the nursing process and identify anticipated needs of the client that include physiological, psychosocial, developmental, environmental factors, client education and discharge planning needs as identified by nursing diagnosis." It further states, (under "Procedures" subsection for Registered Nurses (RN)) that
"Following the admission assessment, will prioritize identified needs and formulate nursing diagnosis"

"Individualize the Care Plan utilizing patient assessment and history data. Care plans that are not individualized are not acceptable"

"Sign and date the developed plan of care and each entry or revision thereafter"

"Upon discharge of client, nurse will document a discharge summary and evaluate outcome of nursing interventions"

"Evaluate and document the outcome of nursing interventions. Indicate date and status of expected outcomes on the Care Plan under evaluation"

2. Medical record review revealed Patient #11 was admitted on 2/4/12 (as an observation, became full admit on 2/5/12) with diagnoses of lung cancer, radiation esophagitis, symptomatic anemia, dehydration, leukopenia, hypokalemia, hyponatremia and dysphagia. During her stay she received a percutaneous epigastric (PEG) tube. She received a chest tube for a pneumothorax. She received two (2) units of packed red blood cells. The following problems were listed on her Interdisciplinary Plan of Care (IPOC) but had no Plan of Care/Interventions: Protection, Patient Orientation, Patient Education, Pain Management, Activity, Coping, Infection, Fluid and Electrolyte Balance.

3. Medical record review revealed Patient #12 was admitted on 1/30/12 (came in initially as observation and switched to full admit on 1/30/12). Her diagnoses included urosepsis, anemia, dehydration, hypertension, diabetes mellitus and coronary artery disease. She has a history of a cerebral vascular accident (CVA). Dehydration, Diabetes, hypertension and coronary artery disease are not addressed in her IPOC. Urosepsis is listed as a problem in "Safe Patient Handling"; and there are no nursing interventions. Infection is not initiated as a problem. The following problems were listed on her IPOC but had no Plan of Care/Interventions: Protection, Patient Education, Discharge Planning, Pain Management, Impaired Mobility, Potential for Anxiety, and Safe Patient Handling.

There are no staff names or staff signatures on any page of the IPOC.

4. The Director of Nursing (DON) was interviewed on 5/1/12 at 1040. The Medical Surgical Nurse Manager was interviewed on 5/2/12 at 1400. Both agreed that the above referenced care plans were not initiated or completed according to their expectations or policy.

Based on medical record review and staff interview, it was determined the hospital failed to provide four (4) of four (4) swing bed patients with an ongoing program of activities (patients #7, 8, 9 and 10). This failure creates the potential for the physical and psychosocial well being of all swing bed patients to be adversely affected.

Findings include:

1. The closed medical records of patients #8, #9, #10 and the open record of patient #7 were reviewed. Review of the Activity Sheets in all four (4) of these records revealed that activities of daily living (ADLs) were listed. These included ADLs such as "getting a bath", "sitting in chair reading newspaper", "went to bed", and "on bedpan".

2. The Medical Surgical Nurse Manager was interviewed on 5/1/12 at 1040 a.m. She agreed that activities listed are ADLs and indicated she recognizes this is a problem. The Director of Nursing (DON) was interviewed on 5/1/12 at 1300. She agreed that activities listed are ADLs and acknowledged this is a problem.

3. On 4/30/12 at approximately 1300 an interview was conducted with the DON. She stated the facility does not currently have an Activities Director (AD). She stated the previous AD left employment in February 2012.

4. An interview was conducted with the Medical Surgical Nurse Manager on 5/1/12 at 1040. She stated that Certified Nursing Assistants (CNA) are now doing "activities" with the patients. She expressed concern that the CNAs lack the training to perform these tasks as evidenced by the documentation on the Activity Sheets.

5. On 5/1/12 at 1300 the DON stated when the AD left in February 2012 it was decided the current Social Worker (SW) would fill the role of AD. She noted the SW missed her first opportunity for training which is only offered once per year. She stated the facility made an arrangement to have the SW individually trained, noting the SW has not had this training because she has been off work for an extended period due to illness. She indicated it is unknown when the SW will return to work. The DON agreed that currently CNAs are performing activities with patients and agreed that the lack of an AD is problematic.

Based on review of documents, medical records and staff interview, it was determined the facility failed to ensure comprehensive care plans are developed for each swing bed resident that include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. This practice impacted two (2) of two (2) swing patients reviewed with an admission of twenty-one (21) days or greater (patients #7 and #10). This failure creates the potential for the care of all patients to be negatively affected by not accurately identifying and documenting actual and potential patient conditions which is crucial to attaining or maintaining the resident's highest practicable physical, mental, and psychosocial well being.

Findings include:

1. The current Swing Bed Policy for Comprehensive Care Plans, dated 5/87, revised 12/99, states under "Content of the Overall Plan of Care", "Objectives should be developed to assure the attainment or maintenance of the highest practible level of physical, mental and psychosocial well being".

2. Medical record review revealed Patient #7 was admitted on 4/11/12 and is a current patient. Her admission diagnoses include: congestive heart failure (CHF), respiratory failure, weakness and dementia. Her comorbidities and medical history include: lung cancer, chronic obstructive pulmonary disease (COPD), atrial fibrillation, mitral valve prolapse (MVP) with mitral valve replacement, peripheral vascular disease (PVD), osteoarthritis and coronary artery bypass graft. The chart has a Braxton County Memorial Hospital (BCMH) "Swing Bed Assessment" with a blank date. Medically defined conditions and prior medical history are identified by the assessor as follows: atrial fibrillation, increased lipids, CHF, coronary artery disease, pulmonary edema, arthritis, COPD, cataracts to the left eye. The only problems addressed on the patient's pre-printed "Nursing Swing Bed Care Plan" are: Activity Intolerance, Patient Orientation, Risk for Impaired Skin Integrity, Risk for Falls and Pain Management (no pain intensity goal is given).

3. Medical record review revealed Patient #10 was admitted on 2/8/12 and discharged on 3/6/12. His admission diagnosis include: Left hip fracture with Open Reduction Internal Fixation (ORIF), alzheimer's, dementia, diabetes mellitus, benign prostatic hyperplasia (BPH) with retention, kidney stones, osteoarthritis, gastroesophageal reflux (GERD), chronic back pain with three (3) back surgeries, pernicious anemia and Vancomycin Resistant Enterococcus (VRE) faecalis bronchitis. History is the same. Patient had a Foley catheter placed during this admission. The record has a BCMH "Swing Bed Assessment" dated 2/8/12. Medically defined conditions and prior medical history are identified by the nurse as follows: arthritis, hip fracture "R & L", depression, emphysema, COPD, kidney stones, BPH, and "mild reflux disease". The only problems addressed on the patient's pre-printed "Nursing Swing Bed Care Plan" are: Activity Intolerance, Patient Orientation, Risk for Impaired Skin Integrity, Risk for Falls and Pain Management.

4. The Swing Bed Director is currently on leave. On 5/1/12 at 1040 the Medical Surgical Nurse Manager was interviewed. She stated if a patient has a diagnosis(es) other than those on the pre-printed "Nursing Swing Bed Care Plan", it is her expectation that the Registered Nurse (RN) obtain an additional form and initiate that problem or problems. She agreed that was not done for these patients. The Medical Surgical Nurse Manager further agreed that a comprehensive care plan should encompass those conditions identified in the BCMH Swing Bed Assessment as well as admission diagnosis(es), comorbidities and history. On 5/1/12 at 1300 the DON was interviewed and indicated her expectation for comprehensive care plans mirror those of the Medical Surgical Nurse Manager.