HospitalInspections.org

Based on observation, medical record review and staff interview, the facility failed to ensure a comprehensive care plan that addressed all patient concerns was developed for 9 of 20 sample patients (#2, #5, #6, #11, #12, #13, #15, #19, #20). The findings were:

1. Medical record review showed patient #2 was admitted to the facility on 10/23/14 with diagnoses which included end stage renal disease and dehydration. The review showed the patient had received a kidney transplant 18 years prior to admission, and the transplant was failing. At that time the patient chose not to receive another kidney transplant, and chose not to start dialysis. Instead, the patient chose comfort measures for end of life. Review of the care plan showed a plan to address pain that included assessment of the patient's pain every shift and as needed. The following concerns were identified:
a. The plan failed to address how the patient's pain level (example: scale of 0 to 10 with 0 being pain free) would be assessed and determined, and what level of pain would not be acceptable by the patient.
b. The plan called for staff to monitor effectiveness of pain medication. The plan also called for staff to coordinate with pharmacy regarding pain goal, development, and implementation as needed. However, the plan failed to specify what staff were to do if the patient had an unacceptable level of pain.

2. Medical record review showed patient #5 was admitted to the facility on 9/11/15 with diagnoses which included abdominal pain, ileus, and small bowel obstruction. Observation of the patient on 9/14/15 at 3:45 PM showed s/he had a naso-gastric tube (tube inserted via nare to the stomach). The patient stated that s/he had not been allowed any oral intake since admission (3 days), and would be allowed oral intake later that evening. Review of the patient's care plan showed there was a plan to address pain and nutrition deficits. The following concerns were identified:
a. The plan to address pain stated to assess pain location, quality, and intensity. However, the plan failed to address how the patient's level (example: scale of 0 to 10 with 0 being pain free) would be assessed and determined, and what level of pain would not be acceptable by the patient.
b. The plan to address pain called for staff to evaluate prescribed analgesic effectiveness 30-60 minutes post administration. However, the plan failed to specify what staff were to do if the patient had an unacceptable level of pain.
c. The plan to address nutrition deficit stated the goal was to demonstrate progressive weight gain, and identify methods to increase intake. The plan failed to address the patient's NPO (nothing by mouth) status, the patient's nasogastric tube, or any interventions to assist the patient with weight stability.

3. Medical record review showed patient #6 was admitted to the facility on 9/11/15 with diagnoses which included seizures, liver transplant failure, alcohol intoxication, and alpha-1 antitrypsin disorder. The review showed the patient had stopped taking anti-rejection medication for a liver transplant about one month prior to admission, and resumed drinking alcohol. Review of the care plan showed a plan to address pain that included assessment of the patient's pain every shift and as needed. The following concerns were identified:
a. The plan stated to assess pain location, quality, and intensity. However, the plan failed to address how the patient's level (example: scale of 0 to 10 with 0 being pain free) would be assessed and determined, and what level of pain would not be acceptable by the patient.
b. The plan called for staff to evaluate prescribed analgesic effectiveness 30-60 minutes post administration. However, the plan failed to specify what staff were to do if the patient had an unacceptable level of pain.

4. Medical record review showed patient #11 was admitted to the facility on 8/4/15 with diagnoses which included abdominal pain. According to the 8/4/15 physician's emergency department documentation, the patient had paralysis, a colostomy, and suprapubic urinary catheter. Further review revealed a naso-gastric tube was inserted in the patient's stomach before she/he was admitted to the medical surgical unit. Review of the care plan showed care of the colostomy, naso-gastric tube and urinary catheter were not included in the care plan.

5. Medical record review showed patient #20 was admitted to the facility on 7/24/15 with diagnoses which included post dental extraction bleeding gums. Review of the 7/26/15 physician's documentation showed the patient received anticoagulation medications due to a mechanical conduit (aortic valve) and a history of stroke. Review of the care plan showed interventions were developed to address pain, anxiety and falls. Further review showed interventions related to monitoring for bleeding and anticoagulation therapy were not developed to address this specific patient care need.

6. Medical record review showed patient #12 was admitted to the facility on 6/26/15 with diagnoses which included recurrent seizures and subdural hematoma. Review of the 6/30/15 physician's discharge summary showed the patient required transfer to another facility for care of ongoing seizures. Review of the care plan showed seizures and potential effects of a subdural hematoma were not addressed in the care plan.

7. Medical record review showed patient #15 was admitted to the facility on 6/11/15 with diagnoses which included exacerbation of congestive heart failure and dementia. Further review revealed the patient had a urinary catheter and was totally dependent on staff to provide this care. Review of the care plan revealed care of the urinary catheter had not been included in the care plan.

8. Medical record review showed patient #13 was admitted to the facility on 1/14/15 with diagnoses which included infected wound. Review of the 1/14/15 physician's documentation showed the patient was receiving anticoagulation medication due to a pulmonary embolus. Review of the care plan showed interventions related to monitoring for bleeding and anticoagulation therapy were not developed to address this specific patient care need.

9. Medical record review showed patient #19 was admitted to the facility on 8/30/15 with diagnoses which included vomiting, bowel obstruction and an ileal conduit (system of urinary drainage which a surgeon creates using the small intestine after removing the bladder). Review of the emergency department documentation, dated 8/30/15, showed a naso-gastric tube was inserted into the patient's stomach prior to transfer to the medical surgery floor. Review of the care plan showed care of the naso-gastric tube and ileal conduit had not been addressed in the care plan.

10. During an interview on 9/16/15 at 4:45 PM, the registered nurse (RN) clinical informatics coordinator verified the above care plans did not address all of the patients' problems. She stated care plans were important because they drive the care. She further stated the computer software was available for staff to develop more comprehensive and individualized care plans, but staff were not using it.