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Based on record reviews, staff interviews and review of the facility's policy and procedure, the facility failed to ensure the nursing staff developed and kept current, a nursing care plan for each patient for 9 of 34 patients (Patients #14, 15, 17, 25, 27, 28, 32, 33 and 34 ) in the case sample.

Findings include:

1. On 3/22/11 at 2:40 P.M., three active clinical record reviews for patients #14, #15 and #17 were completed on the cardiac monitoring unit. Patient #14 was admitted on 3/20/11 with diagnoses including atrial fibrillation with rapid ventricular response, hypertension and chest pain rule out myocardial infarction. Patient #15 was also admitted on 3/20/11 with diagnoses including atrial fibrillation, atrial flutter and pneumonia. Patient #17 was admitted on 3/19/11 with diagnoses including congestive heart failure, hypotension, dementia and hyperlipidemia.

During the concurrent electronic medical record (EMR) review with a licensed staff on the unit, it was found there were no nursing care plans developed for patients #14, 15 and 17. The licensed staff stated the development of a nursing care plan "should be done on admission" and verified no care plans had been initiated or developed for these patients. The licensed staff stated it was usually the nurse admitting the patient who would create the nursing plan of care. She stated with the EMR, although it was noted on the computer screen as a care item to add a problem to the plan of care "On Admit," the licensed staff confirmed it was not consistently being done. At 3:25 P.M., the unit's Nurse Manager stated, "we actually do chart checks every 12 hours to ensure care plans are developed." She said these three patient charts happened to be the ones without nursing care plans.

2. Clinical record reviews were conducted on 03/22/11 at approximately 3:00 p.m. for active patients on the 2nd floor surgical/pediatric unit. The Medical Services Supervisor for the unit provided access to the EMR. Patients # 25, 27, 28, 32, 33 and 34 had no documentation of a nursing care plan in their EMR. For Patients #25, 27, 28, 32, 33 and 34, there were nursing interventions listed but according to the Medical Nursing Supervisor, those interventions were not considered nursing care plans. Patient #25 was admiited on 03/21/11 for swelling to the testicles; Patient #27 was admitted on 03/15/11 for congestive heart failure, abdominal pain and sleep apnea; Patient #28 was admitted on 03/20/11 for multiple traumatic injuries due to a motor vehicle accident; Patient #32 was admitted on 03/22/11 for left shoulder acroplasty due to tendonitis; Patient #33 was admitted on 03/21/11 for diverticulitis; and, Patient #34 was admitted on 03/17/11 for necrotizing fascitis requiring a skin graft.


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3. Clinical record reviews were conducted on 03/22/11 at approximately 3:00 p.m. for active patients on the 2nd floor surgical/pediatric unit. The Medical Services Supervisor for the unit provided access to the EMR. Patients # 25, 27, 28, 32, 33 and 34 had no documentation of a nursing care plan in their EMR. For Patients #25, 27, 28, 32, 33 and 34, there were nursing interventions listed but according to the Medical Nursing Supervisor, those interventions were not considered nursing care plans. Patient #25 was admiited on 03/21/11 for swelling to the testicles; Patient #27 was admitted on 03/15/11 for congestive heart failure, abdominal pain and sleep apnea; Patient #28 was admitted on 03/20/11 for multiple traumatic injuries due to a motor vehicle accident; Patient #32 was admitted on 03/22/11 for left shoulder acroplasty due to tendonitis; Patient #33 was admitted on 03/21/11 for diverticulitis; and, Patient #34 was admitted on 03/17/11 for necrotizing fascitis requiring a skin graft.

A review of the facility's policy and procedure, "Assessment/Admission Of Patients," No. 300-104-101, noted that upon the completion of an interdisciplinary assessment, an interdisciplinary care plan was to be developed. The policy further stated for in-patients, "1. At the time of admission, all patients will have an initial physical, psychological, and social status assessment completed by a registered nurse, to facilitate development and implementation of a plan of care that will best meet the individualized healthcare needs of the patients." Although the nursing admission assessments were found in the patients' EMRs, there was no evidence of the development of nursing plans of care for Patients #14, 15, 17, 25, 27, 28, 32, 33 and 34.

Based on record review and staff interview, the hospital did not ensure that all orders, including telephone orders, were dated, timed and signed promptly by the ordering physician for 1 random sampled closed record.

Finding includes:


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On 03/21/2011 at approximately 3:00 p.m., a tour of the Medical Records Department was conducted. The Medical Record Librarian (MRL) demonstrated security measures for access to an electronic medical record and provided an accompanying paper medical file for a random discharged patient. There was a telephone order dated 03/19/11 to discontinue an antibiotic. The order was not authenticated by the ordering physician, as the documentation lacked the physician's signature, date and time. The MRL stated that nursing staff should have tagged or faxed the order to the ordering physician within 24 hours after receiving the telephone order to authenticate the telephone order.

Based on record review, staff interviews and review of the facility's policy and procedure, the facility failed to ensure an occupational therapy screening was completed per the treatment plan for 1 of 34 patients (Patient #24) in the case sample.

Finding includes:

On 3/23/11 at approximately 9:00 A.M., a concurrent clinical record and EMR review of Patient #24 was conducted with the nurse manager in the behavioral health unit (BHU). Patient #24 was seen in the emergency department and subsequently admitted to the BHU on 3/21/11 at 12:30 P.M. It was also noted that "Occupational therapy" was listed in patient #24's physician's treatment plan. The nurse manager explained that every patient admitted to the BHU was to be screened by occupational therapy (OT) within 3 calendar days, except weekends and holidays and produced Policy No. 638-103-04. The nurse manager stated the OT screen was performed to determine the necessity of a Kohlman Evaluation of Living Skills (KELS), which evaluated a patient's ability to live independently.

Record review found that patient #24's OT screen had not yet been completed and it was the patient's admission day 3. On the afternoon of 3/23/11 at approximately 1:30 P.M., during interviews with the unit's nurse manager, the director of OT and the unit's nursing supervisor, it was revealed that OT and BHU were scheduled to meet with the Chief Nurse Executive (CNE) to initiate a new plan to ensure the provision of OT services for screening/evaluation would not be delayed for the BHU patients, which was found for patient #24.

Based on record reviews, staff interviews and review of the facility's policy and procedure, the facility failed to ensure the nursing staff developed and kept current, a nursing care plan for each patient for 9 of 34 patients (Patients #14, 15, 17, 25, 27, 28, 32, 33 and 34 ) in the case sample.

Findings include:

1. On 3/22/11 at 2:40 P.M., three active clinical record reviews for patients #14, #15 and #17 were completed on the cardiac monitoring unit. Patient #14 was admitted on 3/20/11 with diagnoses including atrial fibrillation with rapid ventricular response, hypertension and chest pain rule out myocardial infarction. Patient #15 was also admitted on 3/20/11 with diagnoses including atrial fibrillation, atrial flutter and pneumonia. Patient #17 was admitted on 3/19/11 with diagnoses including congestive heart failure, hypotension, dementia and hyperlipidemia.

During the concurrent electronic medical record (EMR) review with a licensed staff on the unit, it was found there were no nursing care plans developed for patients #14, 15 and 17. The licensed staff stated the development of a nursing care plan "should be done on admission" and verified no care plans had been initiated or developed for these patients. The licensed staff stated it was usually the nurse admitting the patient who would create the nursing plan of care. She stated with the EMR, although it was noted on the computer screen as a care item to add a problem to the plan of care "On Admit," the licensed staff confirmed it was not consistently being done. At 3:25 P.M., the unit's Nurse Manager stated, "we actually do chart checks every 12 hours to ensure care plans are developed." She said these three patient charts happened to be the ones without nursing care plans.

2. Clinical record reviews were conducted on 03/22/11 at approximately 3:00 p.m. for active patients on the 2nd floor surgical/pediatric unit. The Medical Services Supervisor for the unit provided access to the EMR. Patients # 25, 27, 28, 32, 33 and 34 had no documentation of a nursing care plan in their EMR. For Patients #25, 27, 28, 32, 33 and 34, there were nursing interventions listed but according to the Medical Nursing Supervisor, those interventions were not considered nursing care plans. Patient #25 was admiited on 03/21/11 for swelling to the testicles; Patient #27 was admitted on 03/15/11 for congestive heart failure, abdominal pain and sleep apnea; Patient #28 was admitted on 03/20/11 for multiple traumatic injuries due to a motor vehicle accident; Patient #32 was admitted on 03/22/11 for left shoulder acroplasty due to tendonitis; Patient #33 was admitted on 03/21/11 for diverticulitis; and, Patient #34 was admitted on 03/17/11 for necrotizing fascitis requiring a skin graft.


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3. Clinical record reviews were conducted on 03/22/11 at approximately 3:00 p.m. for active patients on the 2nd floor surgical/pediatric unit. The Medical Services Supervisor for the unit provided access to the EMR. Patients # 25, 27, 28, 32, 33 and 34 had no documentation of a nursing care plan in their EMR. For Patients #25, 27, 28, 32, 33 and 34, there were nursing interventions listed but according to the Medical Nursing Supervisor, those interventions were not considered nursing care plans. Patient #25 was admiited on 03/21/11 for swelling to the testicles; Patient #27 was admitted on 03/15/11 for congestive heart failure, abdominal pain and sleep apnea; Patient #28 was admitted on 03/20/11 for multiple traumatic injuries due to a motor vehicle accident; Patient #32 was admitted on 03/22/11 for left shoulder acroplasty due to tendonitis; Patient #33 was admitted on 03/21/11 for diverticulitis; and, Patient #34 was admitted on 03/17/11 for necrotizing fascitis requiring a skin graft.

A review of the facility's policy and procedure, "Assessment/Admission Of Patients," No. 300-104-101, noted that upon the completion of an interdisciplinary assessment, an interdisciplinary care plan was to be developed. The policy further stated for in-patients, "1. At the time of admission, all patients will have an initial physical, psychological, and social status assessment completed by a registered nurse, to facilitate development and implementation of a plan of care that will best meet the individualized healthcare needs of the patients." Although the nursing admission assessments were found in the patients' EMRs, there was no evidence of the development of nursing plans of care for Patients #14, 15, 17, 25, 27, 28, 32, 33 and 34.

Based on record review and staff interview, the hospital did not ensure that all orders, including telephone orders, were dated, timed and signed promptly by the ordering physician for 1 random sampled closed record.

Finding includes:


29600

On 03/21/2011 at approximately 3:00 p.m., a tour of the Medical Records Department was conducted. The Medical Record Librarian (MRL) demonstrated security measures for access to an electronic medical record and provided an accompanying paper medical file for a random discharged patient. There was a telephone order dated 03/19/11 to discontinue an antibiotic. The order was not authenticated by the ordering physician, as the documentation lacked the physician's signature, date and time. The MRL stated that nursing staff should have tagged or faxed the order to the ordering physician within 24 hours after receiving the telephone order to authenticate the telephone order.

Based on record review, staff interviews and review of the facility's policy and procedure, the facility failed to ensure an occupational therapy screening was completed per the treatment plan for 1 of 34 patients (Patient #24) in the case sample.

Finding includes:

On 3/23/11 at approximately 9:00 A.M., a concurrent clinical record and EMR review of Patient #24 was conducted with the nurse manager in the behavioral health unit (BHU). Patient #24 was seen in the emergency department and subsequently admitted to the BHU on 3/21/11 at 12:30 P.M. It was also noted that "Occupational therapy" was listed in patient #24's physician's treatment plan. The nurse manager explained that every patient admitted to the BHU was to be screened by occupational therapy (OT) within 3 calendar days, except weekends and holidays and produced Policy No. 638-103-04. The nurse manager stated the OT screen was performed to determine the necessity of a Kohlman Evaluation of Living Skills (KELS), which evaluated a patient's ability to live independently.

Record review found that patient #24's OT screen had not yet been completed and it was the patient's admission day 3. On the afternoon of 3/23/11 at approximately 1:30 P.M., during interviews with the unit's nurse manager, the director of OT and the unit's nursing supervisor, it was revealed that OT and BHU were scheduled to meet with the Chief Nurse Executive (CNE) to initiate a new plan to ensure the provision of OT services for screening/evaluation would not be delayed for the BHU patients, which was found for patient #24.