HospitalInspections.org

Based on review of facility policies and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that nursing care plans were reviewed and revised as necessary for one of 18 medical records reviewed (MR21).

Findings include:

Review of the facility's policy, "Restraint/Seclusion Management", approval date April 2010, revealed "F. Documentation of Patients in Restraints in Acute Medical & Surgical (Non-Violent or Non-Self-Destructive Care) 1. Each episode of restraint is recorded. Documentation includes but may not be limited to the following information: ... m. RN (Registered Nurse) documentation every 24 hours on the Interdisciplinary Plan of Care."

Review of MR21's admission of May 29, 2010, revealed a physician's order for the initiation of restraints from June 5, 2010, through June 7, 2010. There was no documentation that the RN had reviewed the plan of care for June 6 and 7, 2010.

Review of MR21's admission of July 8, 2010, revealed a physician's order for the initiation of restraints from July 18 through July 19, 2010. There was no documentation that the RN had reviewed the plan of care for July 19, 2010.

Interview with EMP2 on January 3, 2010, at approximately 4:30 PM confirmed there was no review of care plans for these two admissions.

Based on review of facility policy and procedure, medical records (MR), and interview with staff (EMP), it was determined the facility failed to document patient attendance and participation at group therapy in three of three open medical records reviewed (MR1, MR2, and MR3).

Findings include:

Review of facility policy "Patient Records/Charting", effective January 2010, revealed "Patients have a separate hospital record to provide an accurate record of assessments, treatment, recovery, and continuity of care. The record is comprehensive, thorough, legible and compiled in a timely manner with all required forms and documents. ... 2. Complete chart entries using these guidelines: ... q. All groups are to be charted separately using the Bio-psychosocial Participation Record daily..."

Review of MR1 revealed the patient was admitted on December 30, 2010. There was no documentation that the patient attended and participated or refused to attend the group therapy on the afternoon of December 31, 2010, and the afternoon of January 2, 2011.

Review of MR2 revealed the patient was admitted on January 1, 2011. There was no documentation that the patient attended and participated or refused to attend group therapy for January 1 and 2, 2011.

Review of MR3 revealed the patient was admitted on January 1, 2011. There was no documentation that the patient attended and participated or refused to attend the group therapy for the afternoon of January 2, 2011.

Interview with EMP1 on January 3, 2011, at approximately 1:30 PM confirmed there was no documentation of group attendance and participation for these medical records. EMP1 confirmed there were two group therapy sessions in the morning and two group therapy sessions in the afternoon.