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Based on observation and interview the facility failed to ensure hospital staff were following current standards of practice for patient safety in one (1) out of five (5) patients (ID # 9) that had a tracheostomy.

Findings Included:

Observation with the Charge Nurse, (ID# 56) on 10/18/2018 at 1330 at the beside of 74-year-old- patient (ID # 9), who was admitted with acute respiratory failure and multiple strokes. It was revealed that there was not a replacement 8 Shiley tracheostomy (trach) at the bedside.

Interview on 10/18/2018 at 1330 with the charge nurse (ID # 56) RN, she stated all patients with tracheostomy should have a replacement trach at the bedside.

Record review of the facility policy "Tracheostomy, Routine Care, T.3" dated 05/2017 revealed:
Once the procedure is performed, the obturator and a second tracheostomy tube of the same size will be kept at the bedside.

Based on interview and record review the facility failure to ensure nursing staff kept nursing care plans current to address the patients' needs for 5 out of 12 patients' (ID #1, 2, 3, 5, 7).

Findings:

Patient (ID# 1) a 92-year-old male was admitted for extensive wound care, his nursing care plan revealed multiple nursing diagnosis but was not updated within 12-24 hours on multiple occasions as stated in policy.

Patient (ID #2) a 29-year-old male was admitted for left upper quadrant abdominal abscess. His nursing care plan revealed multiple nursing diagnosis but was not updated within 12-24 hours on multiple occasions as stated in hospital policy.
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Patient (ID#3) a 69-year-old female was admitted for cellulitis and wound care. Her nursing care plan addressed several multiple nursing diagnoses but was not updated within 12-24 hours on multiple occasions as state in hospital policy.

Patient (ID#5) a 69-year-old female was admitted for respiratory failure and failed address her medical issues (sepis, and renal failure). The care plan was not updated within 12-24 hours as stated in hospital policy.

Patient (ID#7) an 83-year-old male was admitted for respiratory failure and wound care. The interdisciplinary plan of care was not updated within 12-24 hours as stated in hospital policy.

Record review of the current hospital policy titled "Interdisciplinary Plan of Care" dated 07/18 stated:

The Interdisciplinary Care Plan will be initiated by the Registered Nurse within 24 hours of admission and re-evaluated every 12-24 hours.

Interview with the CNO (ID #52) on 10/18/2018 at 1300 she stated care plan should be updated at least every 24 hours