HospitalInspections.org

Based on facility staff interview, and record review, the hospital failed to provide a plan of care to meet the patient and family needs for (Patient # 8) one of the 12 patients sampled.

The findings include:

A closed record review for Patient # 8 was conducted on 06/12/2015 at 10:15 a.m. The record review revealed Patient # 8, a newborn was admitted to the facility on 04/12/2014 after being transferred from another hospital. Patient #8 was admitted to the Neonatal Intensive Care Unit (NICU) with the following diagnoses: Respiratory Distress and after cardiac (heart) diagnostics was found to have additional cardiac abnormalities including: a dysplastic, tricuspid valve, tricuspid pulmonary atresia, dilated right atrium and ventricle. The facility care plan contains sections for care concerns. The nursing care plan documentation presented during the survey included various sections of care concerns. A section of the cardiac care plan is identified as, "Alteration in Cardiac Function." Patient #8 underwent multiple cardiac interventions, including open heart valve repair surgery, for cardiac anomalies and dysfunction. This section of the care plan was blank (without entry). Patient #8 experienced multiple condition deteriorations during his hospital stay. The parents were actively at bedside as documented in the physician progress notes and the Pediatric Intensive Care Unit (PICU). Section 1 of the hospital care plan is dedicated to the Patient/Family education and coping concerns. This section of the care plan was blank (without entry). The Care plan lacked coping interventions, plans and goals for the coping support mechanisms for the parents and family. A review of the record revealed, Patient #8 experienced a continual deterioration and decline in condition. On April 30, 2014, the parents made the decision to remove life support and Patient #8 expired after life support was removed. The Nurse Director explained, during an interview conducted on 06/12/2015 at 10:30 a.m., "We would expect the care plan to be completed and updated by the nurse as needed." The Nurse Director was asked if the care plan was complete, including cardiac condition and coping care for the parent was included in the care plan. The Nurse Director stated, "The care plan was not complete or updated for the condition change. " The Assistant Administrator stated, "We could do better with this."