HospitalInspections.org

Based on electronic record review, review of policy and procedure, and staff interviews, the facility failed to initiate a care plan for 1 (Patient #1) of 3 monitored patients who presented with cardiac problems and a change in condition.

The findings include:

1. Review of the electronic medical record for Patient #1 revealed the patient presented to the Emergency Department (ED) on 11/04/22 at 4:27 PM with chest pain. The Electrocardiogram (ECG) revealed Atrial Fibrillation with Rapid Ventricular Rate (A-fib with RVR). Patient #1 was admitted to telemetry on three South. There was no care plan initiated on admission, or throughout the admission, regarding Patient #1's cardiac medical problems.

2. A review of the hospital-wide Policy and Procedure titled "Interdisciplinary Plan of Care (IPOC)" with an effective date of 03/2022 was conducted. Page three states, "At a minimum, the IPOC is to be reviewed by the patient's primary nurse every twenty-four (24) hours.

3. On 12/13/22 at 3:45 PM an interview was conducted with Employee B, Risk Manager. She confirmed that Patient #1 should have had an Interdisciplinary Plan of Care (IPOC) initiated upon admission. She confirmed Patient #1 did not have an IPOC initiated.