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HOLSTON VALLEY MEDICAL CENTER
NURSING CARE PLAN
Tag No.: A0396
Based on medical record review, observation, and interview, the facility failed to develop and keep current a care plan for one patient (#1) of five sampled patients.
The findings included:
Patient #1 was admitted to the facility on November 7, 2011, with diagnoses including Transient Ischemic Attack.
Medical record review of a physician's order dated November 8, 2011, revealed, "Change ASA (aspirin) to Plavix (prevents blood clots)..."
Medical record review of the current care plan on November 9, 2011, revealed respiratory symptoms/interventions were addressed and no documentation regarding neurological symptoms/interventions.
Observation and interview with the alert, oriented patient on November 9, 2011, at 11:22 a.m., revealed the patient wore a heart monitor, and the patient presented to the hospital related to numbness in the right hand.
Interview with Registered Nurse #1 (the unit's clinical leader) on November 9, 2011, at 11:45 a.m., at a nursing station, confirmed the care plan failed to address Patient #1's neurological symptoms.
CONTENT OF RECORD: DISCHARGE SUMMARY
Tag No.: A0468
Based on medical record review and interview, the facility failed to document a discharge summary for one patient (#4) of five sampled patients.
The findings included:
Patient #4 was admitted to the facility on July 21, 2011, with diagnoses including Peripheral Vascular Disease.
Medical record review of a physician's order dated July 24, 2011, revealed, "dc home..." Medical record review of a nurse's note dated July 24, 2011, revealed, "Pt dcd (patient discharged) with family..." Medical record review revealed no documentation regarding a discharge summary.
Interview with the Director of Health Information Services on November 9, 2011, at 3:42 p.m., in the Risk Managment office, revealed the patient was originally admitted for same day surgery and susequently admitted to the facility. Continued interview revealed the patient's status was not changed from "same day surgery" to "admission", and confirmed the facility failed to document a discharge summary for Patient #4.