HospitalInspections.org

Based on record review and interview, the facility failed to insure a medical history and physical (H&P) examination was completed and documented for each patient no more than 30 days before or 24 hours after admission or registration for 1 of 10 sampled patients (#8).

Findings:

Patient #8's record reflected the patient was admitted on 5/29/12 at 10:16 p.m. The H&P was not available on 6/22/12 at 11:45 a.m., when the record was being reviewed.

Interview on 6/22/12 at 11:45 a.m. with the director of Risk Management confirmed the H&P was not on the chart, and that when she called the physician he confirmed it was not dictated.

The facility Medical Staff rules and regulations stated that H&Ps shall be completed within 24 hour of the admission.

Based on record review and interview, the facility failed to insure that the nursing staff develops and keeps current a nursing care plan for each patient for 2 of 10 sampled patient records (#6 & 10).

Findings:

1. Review of records reflected patient #6's record, an 83 year old with documented impaired skin integrity, failed to reflect a documented plan of care addressing the actual or potential impaired skin integrity.

2. Patient #10's record, a 65 year old intensive care unit patient bedridden with impaired skin integrity, failed to reflect a documented plan of care addressing the actual or potential impaired skin integrity.

Interview on 6/22/12 at 4:30 p.m. with the nursing director of ICU confirmed the findings and lacked plans of care addressing the patients' potential or impaired skin integrity.