HospitalInspections.org

Based on record review and interview staff failed to initiate a nursing care plan with interventions and goals to address patient's care needs related to skin in 1 of 10 medical records reviewed (Patient (Pt) #1); and failed to update and revise the nursing care plan with appropriate interventions and goals to reflect patient's care needs related to falls in 1 of 10 medical records reviewed (Pt #1), in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure #23908 titled, "Nursing Documentation" last revised 12/13/2023 revealed,
- "The plan of care is comprised of age and gender/sex-appropriate assessments, screenings, diagnoses/patient problems, goals/outcomes, and patient interventions and is documented in the EHR (Electronic Medical Record)."
- "All inpatients will have an individualized plan of care initiated within 24 hours of admission and documented in the medical record."
- "Care plans can have multiple components/phases. The nurse will initiate only those phases appropriate to the patient's condition."
- "The RN (Registered Nurse) individualizes the plan of care for the patient by selecting the appropriate goals/outcomes and interventions for that patient."
- "The RN may update the plan (s) by adding or deleting or revising outcomes/goals or interventions."
- "Nursing plans of care are initiated based on patient needs, medical diagnosis..."

Review of "Attachment F: Adult-Post Fall Management Procedure" last revised 10/18/2024 revealed,
- "b. Implement/modify risk for falls plan of care as appropriate..."

Review of Pt #1's medical record revealed Pt #1 was admitted to the inpatient hospital unit on 11/23/2024 at 5:30 PM and received surgery on 11/25/2024 for a Small Bowel Obstruction due to an incarcerated incisional hernia; Pt #1 was discharged home on 12/03/2024 at 12:17 PM.

Review of Pt #1's "Evaluation Post Fall" dated 12/01/2024 at 11:11 AM, revealed Pt #1 had an unwitnessed fall in the bathroom on 12/01/2024 at 11:01 AM. Per documentation, Pt #1 "turned around to flush and got tangled in her Vac (wound vac) cord..."

Review of Pt #1's Care Plan Event log revealed a care plan was opened for "At Risk for Falls" on 11/23/2024 at 4:30 PM. Review of the Care Plan Event log dated 12/01/2024 (after the fall on 12/01/24 at 11:01 AM) revealed there was no documentation that staff updated/revised the At Risk For Falls Care Plan in response to Pt #1 falling. Review of the Care Plan Event log dated 12/02/2024 revealed there was no documentation of nursing staff reviewing Pt #1's Risk for Falls Care Plan and progress to goal.

Per interview with Director of Nursing (DON) C on 02/19/2025 at 2:42 PM, DON C stated that if a patient falls, nursing staff should update/revise the Care Plan before the end of the shift. DON C stated that this should be documented and reviewed in the Care Plan Event Log. DON C Stated that Care Plans should be reviewed by nursing staff every shift. DON C was unable to provide documentation of nursing staff updating/revising Pt #1's Care Plan post fall on 12/01/2024, and reviewing/updating the Risk for Falls Care Plan on 12/02/2024.

Review of Physician (surgery) progress note dated 12/01/2024 at 11:36 AM (post op day 6) revealed Pt #1 had an open repair of incisional hernia with mesh placement on 11/25/2024. Per surgery progress note, "robotic incisions well approximated with dermabond. Midline incision is covered with prevena vac (wound vac)...There is noted area of blistering lateral to VAC dressing..."

Review of Pt #1's orders revealed an Inpatient Consult to Wound Care Medical Provider ordered on 12/01/2024 at 2:55 PM.

Review of Pt #1's Inpatient Wound Care Consult Note dated 12/02/2024 at 4:24 PM revealed, "(Pt #1) had a prevena vac in place which was removed on POD #7 (Post Operative Day) leaving a large superficial open wound from what appears to be a deflated blister...TRX (treatment): adaptic followed by ABD abd (abdomen) tape, change daily and prn (as needed) to prevent moist dressing..."

Review of Pt #1 nursing flowsheets revealed a "Wound Abdomen Right Distal Blister" was "First Assessed" on 12/01/2024 at 3:04 PM. Per nursing assessment, the Wound Bed was "Pink;Red", "Hydrogel" Topical Agent applied and a dressing was placed.

Review of Pt #1's Care Plan Event log for 12/01/2024 through 12/03/2024 (discharge), there was no documentation of staff opening a skin/wound Care Plan to address Pt #1's skin concerns.

Per interview with Director of Nursing (DON) C on 02/19/2025 beginning at 3:30 PM, DON C confirmed nursing staff did not open a skin/wound Care Plan. DON C stated that nursing staff should open a nursing Care Plan for skin if there are wounds and skin concerns that require monitoring and treatment.