HospitalInspections.org

Based on record review and interview the hospital failed to ensure nursing staff initiated an individualized nursing care plan for two (Patients #6 and #13) of 20 patients.

This failed practice has the likelihood to result in patients receiving poor quality of care and delayed therapeutic treatment.

Findings:

Patient #6

A review of patient records showed no individualized nursing care plan.

Patient # 13

A review of patient records showed no individualized nursing care plan.



On 03/26/2024, a review of a document titled "Care Plan-Nursing" stated "All patients will have a nursing care plan."

On 03/26/2024, at 2:30 pm, Staff A stated the appropriate nursing care plan for patient #6, and patient #13 was not in t/he patient chart.

Based on record review and interview, the hospital failed to ensure completion of history and physical for two (Patient #12, and #13) of 20 patients.

This failed practice has the likelihood to place patients at risk of receiving poor quality of care from uninformed medical care decisions by healthcare providers.

A review of a document titled "Medical Staff Bylaws Rules and Regulations" read in part, A complete admission history and physical examination shall be completed and on the medical record within twenty-four (24) hours of admission...


Findings:

Patient #12

A review of a document titled "History and Physical Examination" showed no examination date.

Patient #13

A review of a document titled "History and Physical" showed no examination date.


On 3/27/2024, Staff A reviewed the medical record for patient #12 and #13 and stated the there was no way of knowing when the H&P was completed because the date of examination was not documented.