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COREWELL HEALTH GRAND RAPIDS HOSPITALS BUTTERWORTH
NURSING CARE PLAN
Tag No.: A0396
Based on medical record review and interview the facility failed to keep current a nursing plan for 1 out of 4 (#20) adult patients.
Findings include:
On 2/7/13 at approximately 10:30 a.m. during medical record review it was revealed that the care plan for patient #20 was not updated to address new occurrences of skin breakdown . Patient #20 was admitted on 11/19/12 for altered mental status. The initial skin assessment upon arriving to the inpatient floor on 11/20/12 documented a Stage 1 pressure ulcer on the right hip. On 11/23/12 nursing staff documented in the "Skin" area on the assessment flow sheet "rash, reddened, bilateral anterior scrotum and head". On 11/25/13 nursing staff documented in the "Skin" area on the assessment flow sheet "rash, reddened, bilateral anterior, groin, scrotum, head". The plan of care has a section titled "Tissue Integrity Skin" which gives a scoring range of 1-5 with 1 being severely compromised, 5 being not compromised. The patient's initial care plan rated him a 4 and this score remained unchanged throughout his length of stay.
On 2/7/13 at approximately 1:00 p.m. during an interview with Staff B the following was revealed. This surveyor asked "It appears that during this stay this patient developed new skin breakdown, would you agree?" Staff B responded "Yes." This surveyor asked "it also appears that the physician was not notified and that the care plans for this patient were not updated, would you agree?" Staff B responded "Yes." This surveyor asked "Would a change in skin condition prompt a change in score under the Tissue Integrity Skin portion of the care plan?" Staff B responded "Yes." This surveyor asked "It also appears that there were no interventions documented for this new breakdown, would you agree?" Staff B responded "Yes."
NURSING CARE PLAN
Tag No.: A0396
Based on medical record review and interview the facility failed to keep current a nursing plan for 1 out of 4 (#20) adult patients.
Findings include:
On 2/7/13 at approximately 10:30 a.m. during medical record review it was revealed that the care plan for patient #20 was not updated to address new occurrences of skin breakdown . Patient #20 was admitted on 11/19/12 for altered mental status. The initial skin assessment upon arriving to the inpatient floor on 11/20/12 documented a Stage 1 pressure ulcer on the right hip. On 11/23/12 nursing staff documented in the "Skin" area on the assessment flow sheet "rash, reddened, bilateral anterior scrotum and head". On 11/25/13 nursing staff documented in the "Skin" area on the assessment flow sheet "rash, reddened, bilateral anterior, groin, scrotum, head". The plan of care has a section titled "Tissue Integrity Skin" which gives a scoring range of 1-5 with 1 being severely compromised, 5 being not compromised. The patient's initial care plan rated him a 4 and this score remained unchanged throughout his length of stay.
On 2/7/13 at approximately 1:00 p.m. during an interview with Staff B the following was revealed. This surveyor asked "It appears that during this stay this patient developed new skin breakdown, would you agree?" Staff B responded "Yes." This surveyor asked "it also appears that the physician was not notified and that the care plans for this patient were not updated, would you agree?" Staff B responded "Yes." This surveyor asked "Would a change in skin condition prompt a change in score under the Tissue Integrity Skin portion of the care plan?" Staff B responded "Yes." This surveyor asked "It also appears that there were no interventions documented for this new breakdown, would you agree?" Staff B responded "Yes."