HospitalInspections.org

Based on interview, record review, and review of facility policy, the Critical Access Hospital (CAH) failed to complete a comprehensive assessment, and failed to develop and implement a comprehensive person-centered care plan for one of four swing bed patients, (Patient (P)14). This deficient practice had the potential to negatively impact the care of any patient admitted to the facility's swing-bed unit by not addressing the patient's activity pursuits, and/or by not providing the appropriate level of assistance required by the patient to carry out their activities of daily living.

Findings include:

1. A review of P14's electronic medical record (EMR) indicated the CAH admitted this adult patient to the swing-bed unit on 07/05/19. His diagnoses included bacteremia (infection of the bloodstream) due to methicillin-sensitive staphylococcal aureus (MSSA), alcohol abuse, septic (infected) arthritis of the left shoulder, type 2 diabetes mellitus, and urinary tract infection. The CAH discharged the patient on 08/02/19.

a. Review of P14's EMR revealed an "Adult Admission Assessment," dated 07/05/19, that addressed the following areas: "General Info [emergency contact, preferred language, chief complaint]," "Pain Assessment," "Advance Directive," "Allergies," "Height & Dose Weights," "Medical History," "Environmental/ Functional [living situation, home treatments, lives with, mobility prior to admission, assistive devices prior to admission]," "Patient Belongings," 'Social Habits [smoke, alcohol, illicit drugs]," "Psychosocial, Cultural/Spiritual," "CSSRS Scale [suicide screening]," "Educational needs," "Learning Style," "DC [discharge] Needs," and "Notification of Hospitalization."

During an interview with Licensed Practical Nurse/Activities Director/Social Services Director (AD/SSD/LPN)1 on 08/27/19 at 3:50 PM, a review of a different section of P14's EMR, "IView," revealed additional comprehensive assessment areas, which the AD/SSD/LPN stated would "drive" the development of the patient's care plan.

Review of the "IView" section of P14's EMR revealed the additional assessment areas included: "Pain," "Neurological," "Respiratory," "Gastrointestinal," "Integumentary," "Musculoskeletal," "Fall Risk," "Safety Information," "Precautions Information," and "Patient Family Education."

None of the assessment areas included in the "Adult Admission Assessment," nor the additional assessment areas in the "IView" section of P14's EMR included an assessment of the patient's vision status, customary routine, mood and behavior, continence status, or his preferred activity pursuits.

b. Further review of the "IView" section revealed the following "Care Plan Goals" for P14: "Goal - Antepartum [before delivery of a baby] Hemorrhage," "Goal - Cardiovascular," "Goal - Circumcision," "Goal - EENT [eyes, ears, nose, throat]," "Goal - Gastrointestinal," "Goal - Impaired Skin Integrity," "Goal - Genitourinary," "Goal - Knowledge Deficit," "Goal - Magnesium Sulfate Therapy [medication used to lower blood pressure and prevent seizures in women who are pregnant]," " Goal - Mobility," "Goal - Neurological," "Goal - Nutrition," "Goal - Pain," "Goal - Parental Involvement," "Goal - Phototherapy," "Goal - Postpartum [after the delivery of a baby]," "Goal - Postpartum Hemorrhage," "Goal - Psychosocial," "Goal - Puncture Site," "Goal - Respiratory," "Goal - Vent [ventilator]," "Goal - Vital Signs," and "Goal - Other."

When asked how the care plan goals listed for P14 were appropriate to his care needs, AD/SSD/LPN1 stated that the computer generated care plan goals from the automated assessment, and did not allow the staff to customize, or individualize the goals for different patients.

During an interview on 08/28/19 at 1:20 PM, the Corporate Quality Manager (CQM) stated the comprehensive assessment lacked an activity assessment and documentation of the patient's involvement. The CQM further stated, ". . . [and] the care plan is missing the individualized goals and the interventions to attain those goals."

During an interview on 08/29/19 at 10:27 AM, the Director of Nursing (DON) stated he could see that the care plan goals were not individualized. When asked for the facility's policy regarding comprehensive assessments and development of comprehensive care plans, the DON replied that he was unable to find a policy regarding a comprehensive assessment, and then stated, "This [the policy provided] was the only policy I could find regarding assessment and/or reassessment for inpatient or swing-bed."

Review of the facility's policy titled, "Scope of Services," revised 06/2018, showed: ". . . 3. Acute Medical and Swing Bed Units . . . e. Assessment/Reassessment: Admission assessment will be completed within 24 hours of admission by Registered Nurse. Patient reassessment will be completed every 12 hours by Registered Nurse or the Licensed Nurse under the supervision of the Registered Nurse."