HospitalInspections.org

Based on policy and procedure review, medical record review and staff interview, the nursing staff failed to develop and/or implement a nursing care plan for 3 of 5 patients (N1, N3 and N5).

Findings:
1. Policy No.: NSI-ADT_02 titled, "Patient Admission/Patient Assessment/Patient Reassessment" was reviewed on 8/2/12 at approximately 12:53 PM and indicated on pg.:
A. 1, under:
i. Policy section, "A registered nurse shall perform or validate a health history, nursing history and physical assessment on all patients admitted to [facility]."
ii. Form Completion Time Frame section, "Identification of patients at high risk for nutrition, falls, skin breakdown..."
B. 2, under High Risk Patient Concerns Upon Admission section, "To document and communicate patient care problems that is identified at the time of admission from nursing homes/home health care agencies."

2. Policy No.: FOOD-NTR_18 titled, "Discharge Planning" was reviewed on 8/2/12 at approximately 12:53 PM and indicated on pg. 1, under Procedure section, "Nursing staff enters order or request for nutrition consult for patient and/or significant other nutrition education...Clinical Dietitian conducts nutrition counseling..."

3. Review of closed patient medical records on 8/2/12 at 11:10 AM, indicated patient:
A. N1 was transferred to the facility from a group home on 5/21/12 at 19:49 PM for a right upper knee abscess with cellulitis. Documentation in the medical record included:
a. per Client Transfer Form dated 5/21/12, "Feeding - needs to be reminded to eat slow."
b. per Multi-Disciplinary Problems (also known as Plan of Care) dated 5/21/12, "Assist with ADL's (activities of daily living)...Collaborate with clinical nutritionist."
c. per Patient Education dated 5/22/12, "Diet Instruction (Done). Description: Provide information on patient's diet. Refer to Dietician, if needed."
d. lacked documentation of a clinical nutritionist and/or dietary consult, as well as dietician notes during patient's length of stay.

B. N3 was was transferred to the facility from another acute care facility for further medical management on 6/21/12 at 05:37 AM for chief complaint of abscess and fever. Documentation in the medical record included:
a. per Ambulance Run Sheet dated 6/21/12 at 04:53 AM, medical history included anxiety and depression and patient was currently taking antidepressant medications.
b. per Problem List, depression documented as being present upon admission, but was not addressed in the Multi-Disciplinary Problems.

C. N4 was transferred to the facility from another acute care facility for further medical management on 7/25/12 at 14:53 PM for cause of injury of suicide attempted or voiced. Documentation in the medical record included:
a. per Ambulance Run Sheet dated 7/25/12 at 14:31 PM, secondary impressions indicated suicidal ideation..."Patient suffers from depression and suicidal ideation and requires constant monitoring."
b. per Nurses' Notes and Multi-Disciplinary Problems dated 7/25/12 through 7/30/12, depression and suicidal ideation was not addressed and suicide precautions were not in place.

4. Personnel P1 was interviewed on 8/2/12 at approximately 12:14 PM and confirmed:
A. plan of care [for patient N1] indicated a need for collaboration with a clinical nutritionist on 5/21/12, however, this was not completed. And, there are no dietician notes in patient N1 medical record. Facility policy and procedure was not followed related to this.
B. the information on a transferring facility's transfer form should be made part of a patient's plan of care. For example, patient needs to be reminded to eat slowly. This was not done for patient N1.

5. Personnel P3 was interviewed on 8/2/12 at approximately 2:26 PM and confirmed:
A. the information documented on the transfer form from the transferring facility, for example: patient needs to be reminded to eat slowly, should be added upon admission to the patient's plan of care, but was not done for patient N1.
B. facility policy and procedure was not followed related to development and implementation of a plan of care for the above-mentioned patients.