HospitalInspections.org

Based on record review and interview, the hospital failed to ensure patient family involvement in placement decisions for one (Patient #4) of twenty patients.

A review of a policy titled "Discharge planning" read in part, "The patient, family and significant others are included in discharge-plan development and implementation."

Patient #4
A review of the medical record showed:
1) the patient experienced intermittent confusion;
2) the patient lived with his sister;
3) no case management documentation included the patient's sister in the decision making process for a facility placement after discharge.

On 2/28/25 at 0950 am, Staff B stated case management documentation didn't show the sister was included in decision making regarding the placement for Patient #4 after discharge.

On 02/28/25 at 12:30 pm, Staff C stated:
1) case management should collaborate with nursing, providers, and therapy to determine placement for a patient;
2) the patient was given three choices of possibe placement; and
3) if the patient had an altered mental status documented in the chart, case management should have reached out to a POA or next of kin for discharge planning.

39648

Based on record review and interview, the hospital failed to ensure care plans addressed the primary diagnosis thus individualizing patient needs for three (Patient #12, 13 and 16) of 20 patients.

Findings:

Patient #12
A review of the initial and updated care plan showed no nursing diagnosis, nursing goals or interventions related to the admitting diagnosis of diabetic ketoacidosis.

Patient #13
A review of the initial and updated care plan showed no nursing diagnosis, nursing goals or interventions related to the admitting diagnosis of gastroenteritis.

Patient #16
A review of initial and updated care plan showed no nusring diagnosis, nursing goals or interventions related to the admission diagnosis of pneumonia.

On 02/28/25 at 10:50 am, Staff B stated the plan of care for Patient #16 failed to address the primary diagnosis at admission or during updates to the plan of care during the duration of the patient stay.

On 2/28/24 at 11:54 am, Staff E stated the care plan is initiated by the charge nurse or admitting nurse if she is an RN. The care plan should be updated by the RN or LPN at least every other shift. The care plans for Patients #12 and 13 did not address the primary diagnosis.