HospitalInspections.org

Based on a review of facility documentation and staff interview, the facility failed to provide documented evidence to 1 of 9 patients (Patient #1), or their legally authorized representatives, to properly document and explain their patient rights prior to discharge.

Findings were:

Record review of current facility policy titled Patient Choice," effective date 08/21/2017, revealed the following:

"The patient representative may authorize signature by phone or fax if the patient is not able to sign and the patient 's representative cannot travel to the hospital."

Record review of Medicare Letter dated 10/9/2017 at 1400 revealed a telephone consent to move patient (ID #1) to Ashford Garden was obtained from the guardian. The documentation was incomplete. No name was written on the consent to indicate who obtained the consent from the guardian.

Record review of the case manager notes dated 10/9/2017 at 2:36 p.m. indicate the legal guardian was notified of the transfer of Patient (ID #1) to Ashford Gardens via voicemail by the Case Manager (ID #65).

Telephone interview with the Chief Nurse (ID #51) on 9/18/2018 at 1100, she stated "the nurse should have signed her name as the person obtaining the consent

Based on interview and record review on 9/5/2018 and 9/6/2018 the facility failed to ensure nursing care plans were kept current by ongoing assessments of the patients' needs and the patient's response to interventions in 9 of 18 patients (4,5, 6,7,9,10,11,15,18).

The hospital must ensure that the nursing staff develops and keeps current, a nursing care plan for each patient. The nursing plan may be part of an interdisciplinary care plan.

Findings include:

Patient (ID #3) a 67-year old male was admitted 9/3/2018 for chest pain he transferred from intensive care unit after a cardiac catheterization, with a diagnosis of renal failure and hypertension. The patients' care plan did not reflect the current care the patient was receiving, dialysis or issues related to hypertension.

Patient (ID # 4) a 65-year-old female, admitted 9/4/2018 with L4 Compression Fracture, s/p Motor Vehicle Accident. The patient did not have a current care plan that address her diagnosis.

Patient (ID # 5) a 80-year female patient admitted for belly pain on 8/22/2018 had surgery for diverticulosis. Patient received an ileostomy, the care plan did not address the patient's intake and output related to her surgical diagnosis.

Patient (ID #6) a 86-year male patient admitted for right knee pain on 9/5/2018, did not a care plan related to his current diagnosis and upcoming surgery.

Patient (ID # 7) a 72-year old female was admitted on 9/4/2017 for urinary incontinence she had a vaginopexy performed on 9/4/2018. The care plan did not address her potential urinary issue, related to her diagnosis.

Patient (ID #9) admitted 8/31/2018 for angina and shortness of breath had coronary artery bypass on 9/4/2018. He was extubated on 9/5/2018 and was sitting up in the chair. The care plan did not address his pain or mobility issues.

Patient (ID #10) admitted 8/31/2018, with a diagnosis of bipolar with an active history of hypoglycemia, and neck pain. The doctor also ordered Cipro 500 mg Q12 hours for urinary tract infection (UTI). The treatment of care did not address the patients' medical issue of UTI.

Patient (ID #11) admitted 8/29/2018, with a diagnosis of bipolar disorder and acute UTI and a history of seizure disorder. The treatment of care does not address the patients' medical issues related to UTI and the seizure disorder.

Patient (ID # 15) admitted 8/8/2018 with a diagnosis of psychosis. The patient was on hydrochlorothiazide 25 mg (1) tab daily for blood pressure and had a potassium level on 3.3 on 8/8/2018. The treatment plan did not address the patient's medical issues.

Patient (ID # 18) admitted 8/13/2018 with a diagnosis of schizophrenia. It was noted in the history and physical the patient had an issue with hypokalemia present on admission. The issue was resolved on 8/23/2018 (potassium was redrawn 3.9). The medical issue was not addressed on the initial treatment of care.

Record review of the current facility policy titled Assessment, Reassessment and Care Planning Policy & Guidelines (IPOC's) dated 11/15/2016:

VI. Content/Focus
a. The nursing assessment in short term and high risk locations (e.g. emergency department, procedural areas) should be focused on the presenting complaints or anticipated procedures.

b. Inpatient nursing assessments and reassessment should be comprehensive and based on the domains reflected in the current nursing documentation system.

Interview with RN (staff ID #51) on 9/7/2018 at 1230 stated the care plans (IPOC's) should reflect the patients care and updated as needed.