HospitalInspections.org

Based on observation, record review and interview it was determined that nursing staff failed to develop and keep current nursing care plans to address patient needs for 8 out of 12 (ID# 3,6,8,10,11,12,13,14) patient records reviewed.

Findings Include: Record review of the facility policy dated 02/16/22 "Interdisciplinary Plan of Care (IPOC), Rehabilitation Nursing" stated the IPOC will be initiated by the RN within 24 hours of admission and evaluated weekly.

Observation and record review of patient records revealed the following:

Patient (ID#3) a 23-year-old male admitted 02/11/2023 with a diagnosis of lupus, end stage renal disease, cerebral hemorrhage, on dialysis. The care plan did not address fluid imbalance, or skin integrity.

Patient (ID#6) 53-year-old male admitted 02/16/2023 with a diagnosis of shock by electric current, he was non-verbal, and unable to follow commands, total care, trach with a peg tub. The care plan did not address nutrition.

Interview with staff nurse (ID#62) on 02/22/23 at 1030, verified the findings in the care plans for patients (ID#3,6).

Patient (ID#8) 63-year-old female admitted 02/17/2023 with a diagnosis of neuromuscular disease and weakness. The care plan did not address potential for aspiration.

Patient (ID#10) 83-year-old female, admitted 02/21/2023 with a diagnosis of polytrauma as a result of an auto pedestrian accident, fractures, she had no other medical issues. The care plan did not address patient's psychological issues related to the accident.

Patient (ID#11) 69-year-old male, admitted 02/14/2023 with a diagnosis of stroke, and a history of diabetes, and developed a wound. The care plan did not address the patient's nutrition status, or his wound.

Patient (ID#12) 70-year-old male, admitted 01/07/2023 with a diagnosis of a spinal cord injury and had a history of diabetes. Care plan did not address diabetes.

Patient (ID#13) 74-year-old female, admitted 02/13/2023 with a diagnosis of an intracranial meningioma, with an altered mental status. Care plan did not address nutrition, potential for skin breakdown, and infection.

Patient (ID#14) 78-year-old female admitted 02/13/2023, post craniotomy, and was on tube feeding. Care plan did not address the patient's seizure risk, impaired bowel and bladder and potential of for skin breakdown.

Interview with staff nurse (ID#61) on 02/22/23 at 1130, verified the findings in the care plans for patients (ID#8,10,11,12,13,14).