HospitalInspections.org

Based upon document review and interview, the facility failed to ensure an individualized plan of care was maintained for 9 of 10 medical records (MR) reviewed (Patient's #1, 2, 3, 4, 5, 6, 7, 8 & 9).

Findings include:

1. Review of the policy/procedure Admission to Clinical Unit, Assessment and Reassessment, and Interdisciplinary Plan of Care (approved 3-19) indicated the following: "Interdisciplinary Plan Of Care (IPOC)...All admitted patients will have a plan of care for treatment and services appropriate to the patient's needs identified by the assessments/reassessments as initiated by the RN... IPOCs are initiated within 24 hours of admission and updated every shift"

2. Review of the MR for Patient's #1, 2, 3, 4, 5, 6, 7, 8 and 9 lacked documentation indicating a nursing care plan was initiated within 24 hours of admission and appropriately updated for each patient.

3. On 8-12-20 at 1010 hours, the Medical Telemetry Manager A6 confirmed a nursing care plan was not identified in the MR for Patient #1 and a copy of the patient's nursing care plan was requested from the Director of Health Information Management A5 and none was provided prior to exit.

4. On 8-12-20 at 1600 hours, the Chief Quality Officer A3 and staff A6 confirmed no nursing care plan documentation for Patient's #1, 2, 3, 4, 5, 6, 7, 8 and 9 was available.