HospitalInspections.org

Based on clinical record review and staff interview, it was determined the nursing care plan did not include interventions to plan the delivery of care for 10 of 10 patients. The failed practice had the potential for patient's health care needs not to be met. The failed practice affected all patients admitted to the facility. The findings were:

A. Review of the clinical records for Patient #1-#10 revealed problems and goals were addressed but there were no developed interventions to plan the care for each patient.
B. During interview on 11/02/11 from 1300 to 1549 with the CNO, RN #1 and RN #2, they confirmed the interventions were not developed as part of the plan of care. Each stated the computer software only allowed them to generate problems and goals but no specific interventions for each identified problem.



Based on clinical record review and staff interview, it was determined of the 10 (#1-#10) clinical records reviewed, four (#1, #4, #5 and #10) patients had skin impairment. The nursing staff failed to accurately assess the skin impairment and failed to include treatment of the skin impairment on the plan of care The failed practices had the potential to affect patients admitted with skin impairment. The findings were:

A. Review of the wound care documentation for Patient #1, #4, #5 and #10 revealed the nursing staff did not descriptively address each patient's wounds related to location, size, depth, drainage, color and odor.
B. During interview on 11/02/11 at 1300 (#10), 1400 (#1), 1545 (#4), 1549 (#5), the clinical records were confirmed as follows: CNO for Patient #10, RN #1 for Patient #1 and RN #2 for Patients #4 and #5.