The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|AURORA ST LUKES MEDICAL CENTER||2900 W OKLAHOMA AVE MILWAUKEE, WI 53215||Sept. 3, 2019|
|VIOLATION: NURSING CARE PLAN||Tag No: A0396|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the nursing staff failed to develop care plans based on the patient's treatment goals in 4 of 10 patients receiving anticoagulation medications, and the nursing staff failed to update and keep current patient nursing goals in 3 of 10 nursing care plans in a total of 10 medical records reviewed.
Review of policy "Nursing Documentation" last revision date 10/25/2018 revealed 4.9 "When documentation... for the plan of care is completed, the nurse... is indicating that that the [Facility] Standards of Nursing practice is followed. The registered nurse also documents the timeframe for accountability, which includes the review of the nursing plan of care and revision as needed... 5.5 Required Ongoing Documentation (a) ... Documentation should reflect patient data obtained during the assessment/reassessment process... (d) ... "progress notes are used to record collaboration with providers... or indicate change in a patient condition... e.g. patient status change..."
Review of policy "Nursing Assessment and Reassessment Inpatient and Hospital Based Departments" last reviewed 5/08/2018 4.9 "The frequency of system assessments is established by venue-specific .. nursing standards, and modified based on patient needs, physician orders or plan of care. 4.10 The registered nurse will establish a plan and frequency for conducting focused assessments based on the patient's risk, symptoms and condition... 4.12 The nurse will notify the physician /LIP (licensed independent practitioner) if there are significant changes in the patient's vital signs based on physician notification standards... 5.2 Minimum Parameters and "Within Defined Limits" (WDL) Findings." Hospital based normal Adult vital signs listed as "Systolic BP (blood pressure): 100 to 140 Diastolic BP: 60 to 90."
Patient #2's medical record was reviewed and revealed Patient #2 was admitted [DATE] with abdominal pain, shortness of breath on exertion, and foot and hand swelling. Patient #2 has a history of pulmonary embolism and deep venous thrombosis on warfarin. History & Physical by Physician G revealed "on warfarin with subtherapeutic INR (international normalized ratio): INR 1.2 on admission. Goal 2-3." There was no care plan for venous thromboembolism.
Patient #3's medical record was reviewed and revealed Patient #3 (MDS) dated [DATE] with shortness of breath, and was admitted [DATE] with respiratory failure, possible community-acquired pneumonia, alcohol abuse, chronic obstructive pulmonary disease, renal failure, and with a medical history significant for [DIAGNOSES REDACTED]on anticoagulation. On 8/06/19 a continuous intravenous heparin infusion was ordered by Medical Doctor H. There was no care plan for venous thromboembolism
Patient #6's medical record review revealed Patient #6 presented to the emergency department 7/26/2019 with a chief complaint of back pain and dehydration with a past medical history of [DIAGNOSES REDACTED]. On 7/28/2019 Patient #6 became significantly short of breath, diagnosed with [DIAGNOSES REDACTED]. On 7/30/19 nursing care plans were initiated for potential for injury, restraints, and skin integrity. There were no nursing care plans initiated for fluid volume excess or ineffective breathing pattern with Patient #6's status change.
Antibiotics were discontinued on 8/05/19. All of the nursing care plans were ended 8/16/19 (including urinary tract infection), the date of discharge. Patient goals in nursing care plan were not updated.
Patient #9's medical record was reviewed and revealed, Patient #9 (MDS) dated [DATE] with leg swelling and heart failure with a history of being on Warfarin for atrial fibrillation/flutter. Patient #9 admitted under the care of MD G with an order placed for pharmacy to monitor Warfarin administration. There is no care plan for venous thromboembolism.
Nursing Interdisciplinary Care Plan template for fluid volume excess was initiated 9/02/19 to monitor "Cardio/peripheral Vascular and Respiratory status" every shift and prn (as needed). Blood pressure was out of normal range (Systolic 100 to 140/Diastolic 60 to 90) on 9/01/19 at 4:26 PM "172/87" at 5 PM "181/102", 5:51 PM "161/77," 9/02/19 at 2:16 PM "165/82, 3:35 PM "175/91" and 11:49 PM "185/89" and 9/03/19 at 1:20 PM "108/55." Patient goals in nursing care plan were not updated and there was no progress note by RN to document collaboration with providers.
Patient #10's medical record was reviewed and revealed Patient #10 was admitted [DATE] with fatigue, shortness of breath, lower extremity swelling, chronic liver disease, and bilateral pulmonary embolism and admitted for anticoagulation management. Nursing interdisciplinary care plan template for pain was initiated 8/06/19 and revealed "Goal: Acceptable pain level achieved/maintained at rest", goal "4" out of 10 (0 = no pain, 10 = severe pain), pain assessment frequency (for Registered Nurse (RN) accountability) "q shift" (every shift) and intervention "Collaborate with provider when pain outcome not met." Review of Patient #10's pain assessment documented by RN dated 8/15/19 at 4:15 PM, "7" "pain level unacceptable." Pain assessment frequency "q shift". "Pain assessment PM shift 8/15/19 at 11 PM "7" "pain level unacceptable". Nursing pain assessment night shift dated 8/16/19 at 3:59 AM revealed "Pain level undetermined-sleeping" pain assessment frequency changed to "q 4 hours" (every 4 hours). AM shift pain reassessment 8/16/19 at 8:30 AM "7" "Pain level unacceptable," pain assessment frequency changed back to "q shift," PM pain reassessment at 4 PM "7", "pain level unacceptable", night shift pain assessment at 11 PM "4" "pain level unacceptable." On 8/17/19 AM day shift pain assessment completed at 9 AM "4" "Pain level unacceptable". PM shift pain assessment at 4:31 PM "8" "Pain level unacceptable" and night shift pain assessment 8/18/19 at 12 AM pain "8" "Pain level unacceptable-add other interventions." Day shift pain assessment 8/18/19 at 9 AM, revealed pain "8" "Pain level unacceptable-contact the provider." PM shift at 8:27 PM pain assessment "8" "Pain level unacceptable-contact the provider." Night shift 8/19/19 at 12:42 AM pain assessment "5" "Pain level acceptable" "Affect/Behavior" assessment "Irritable; Withdrawn." On 8/19/19 at 8 AM Pain Behaviors Evaluation revealed "No behaviors present" and pain assessment frequency changed to "q 4 hours." Patient goals in nursing care plan were not updated, no progress notes by RN to document reason for change of pain reassessment frequency on 8/16/19 or 8/19/19 and no documentation to indicate collaboration with providers to control pain 8/15/19 through 8/19/19.
On 8/30/2019 at 10:00 AM during an interview with Director of Pharmacy D and Director of Nursing B, Director of Nursing B agreed it would be the expectation that a nursing care plan would be initiated for patient's requiring assessment for adjustment of anticoagulation medications.
On 9/03/2019 at 3:25 PM during an interview with Quality Management Director A, Director A confirmed nursing goals "are not always" documented in the nursing care plan, stating they have a "multidisciplinary care plan" and multiple providers document assessment and goals in it, stating "it is not the expectation that patient goals are updated only in the nursing care plan."