HospitalInspections.org

Based on record review and observation the facility failed to develop and keep current a nursing plan of care for 1 of 1 patient record reviewed.


On 9/6/2011 at 9:30 AM the patient medical record was reviewed and revealed the following. The patient was admitted through the Emergency Department (ED) on 3/8/2011.
The ED physician wrote admitting orders with diagnosis as Pneumonia, Hypernatremia, Hypoglycemia, Dehydration and renal insufficiency.
The attending physician for inpatient services dictated the History and Physical as volume depletion, pneumonia, renal failure, dementia and probable aspiration pneumonia.
the admission nurses assessment documented coarse ronchi in lung sounds, incontinent of bowel and bladder, with indwelling catheter,decubiti to medial coccyx,mental status confused with a Gloscow coma score of 14, severe weakness, and bilateral lower extremities with 2 plus edema.

A review of the nursing care plan initiated on 3/8/3011 by staff # 4 revealed: decreased cardiac output, impaired gas exchange, knowledge deficit of dehydration, and activity tolerance. All interventions noted on the nursing care plan were initiated upon admission by staff #4. There was no on-going nursing care plan or intervention for any need identified through the ED physician or attending physician's diagnosis or the admission nursing assessment other than those established upon admission by staff #4. The facility did not meet the needs of the patient through on-going nursing care planning.

An interview with staff #5 confirmed there was no nursing care plan for incontinence, falls risks, skin care, nutritional needs or renal insufficiency/failure and there was no follow-up assessment or intervention to any of the established care plan needs.