HospitalInspections.org

Based on record review and policy review, the nurses did not follow their policy and procedure related to addressing potential issues related to the patient's diagnosis in the intermediate care unit and the intensive care unit in seven (7) out of 11 patients (Patient ID # 12,13,14,16, 17, 19, 20)

Findings Included:

Record review of the facility policy dated 07/2014, "Multidisciplinary Plan of Care Documentation" that stated:

The initial responsibility for the assessment of the inpatient's care and educational needs rest with the Registered Nurse (R.N.)

Subsequent reassessments, made at least every 24 hours by a RN, or finding from consults made to nursing or other specialties may result in additional changes to the Plan of Care.

Record review of the facility policy "Documentation Standards for ICU (Intensive Care Unit)" dated 04/2015. The policy stated, ICU nurse will prioritize the care plan at least once a shift

Record review of five out of eight patients in the intermediate care unit revealed the nurses were not documenting the patients' needs within the nursing care plans.

1. Patient ID# 12, 62-year-old female admitted with arteriosclerosis, had a bypass graft and was also a diabetic. The nurses did not address her history diabetes within their plan or care.

2. Patient ID# 13, a 50-year male admitted for chest pain, who was admitted for a right bundle branch block received a cardiac catheterization and was scheduled for coronary bypass. The nurses did not address the emotional issues related to his impending lifestyle change with his plan of care.

3. Patient ID# 14, a 45-year-old female admitted for chest pain with a history of diabetes, hypertension, and stroke. The nurses did not address her history of diabetes or nutritional teaching in the plan of care.

4. Patient ID# 16, a 92-year-old female admitted for congestive heart failure and pedal edema. The nurses did not address potential for skin breakdown in the plan of care.

5. Patient ID# 17, a 40-year-old male who was admitted for acute coronary syndrome. Discharge was pending, related to a low oxygen saturation. He also obese and had a history of smoking two packs of cigarettes per day for the last 15 years. The nurses did not address nutrition or smoking cessation with the patient within the plan of care.

Record review of the two (2) patient out of three (3) patients in the surgical intensive care unit revealed the nurses were not addressing the patients' needs within the nursing plan of care.

1. Patient ID# 19, a 72-year-old male who was admitted with arteriosclerosis to the right lower extremity. He had a right femoral popliteal bypass with an infected graft, no pulses in his right foot, pending a right foot amputation.

Interview with the staff nurse (ID #59) stated the patient was quite upset and depressed about the possible amputation. The nurses did not address the patients emotional state within the plan of care.

2. Patient ID# 20, a 69-year-old female patient who was admitted for osteomyelitis of the left foot. She had a previous right leg amputation and would be receiving a left leg ampution due to gangrene. Emotional support and a change of lifestyle were not addressed in the nurse's plan of care for patient (ID#20).

Interview with staff nurse (ID# 59) stated on 12/12/2020 at 1130, stated
"Absolutely, we should be addressing these issues".