HospitalInspections.org

Based on patient record review and interview the hospital failed to ensure nursing staff initiated and maintained a nursing care plan for four (Patient # 3, 14, 17, 20) of 21 patients medical records reviewed.

This failed practice has the likelihood to result in delayed recognition and/or treatment of active problems that could influence patient recovery, functional status, and quality of life.

Findings:

A review of the hospital policy titled, "Nursing Care Plan", provided by administration as a current policy, revealed in part: A Registered Nurse plans, evaluates, and supervises the nursing care for each patient. Nursing care plans are based on assessing the patient's nursing care needs and not solely those needs related to the diagnosis and developing appropriate nursing interventions in response to those needs.

A review of Patient #14 medical record revealed in part: Patient #14 was admitted to the hospital on 01/16/2024. The nursing care plan was not initiated .
A review of Patient #17 medical record revealed in part: Patient #17 was admitted to the hospital on 02/27/2024. The nursing care plan was not initiated .
A review of Patient #20 medical record revealed in part: Patient #20 was admitted to the hospital on 02/22/2024. The nursing care plan was not initiated .
A review of Patient #3 medical record revealed in part: Patient #3 was admitted to the hospital on 01/14/2024. The nursing care plan was not initiated .

On 02/26/2024 at 1:30 p.m., durning patient record reviews, staff "A" stated the nursing staff is responsible for initiating and updating with the change in condition nursing care plans for their assigned patients, in the electronic medical record. 21 patient's medical records reviewed four (Patient # 3, 14, 17, 20) nursing care plan were not initiated to address any of the patient's medical problems.


On 02/26/2024 at 1:30 p.m., Staff B stated the nursing plan of care should have been implemented upon admit and updated with the change in condition.

On 02/28/2024 at 11:00 a.m., Staff C stated the nursing care of plan is initiated upon admission. Staff C states a tool is used to audit pain reassessments but not the initial plans of care.

On 02/28/2024 at 11:00 a.m., Staff D stated the nursing plan of care is the responsibility of the admitting assessment nursing staff.