HospitalInspections.org

Based on observation, interview, and administrative document review, the facility failed to ensure registered nursing staff were immediately available to meet patient needs when individual nurses were assigned to two separately certified providers, one for acute care patients and one for Distinct Part Skilled Nursing Facility (DP/SNF) residents.

This failure resulted in nursing staff not being immediately available to care for patients in the acute care setting and had the potential to result in patient harm in the event of an urgent need of an acute care patient while the nurse was in the DP/SNF provider area.

Findings:

On 10/10/16 at 10:10 a.m. during a concurrent observation and interview, House Supervisor (HS) 1 stated Licensed Vocational Nurse (LVN) 2 was assigned to provide care in two separate provider areas, acute care and skilled nursing facility. There were no visible distinctions between the acute care rooms and skilled nursing rooms.

On 10/12/16 at 9:34 a.m., during an interview, LVN 3 stated she was assigned to care for one acute care patient and three SNF residents. She stated it is not unusual to be assigned to acute care patients and SNF residents the same shift.

Hospital documents titled "SNF & Acute Rehab Daily Assignment Sheet" indicated the following licensed nurses were assigned to care for the patients/residents from two separate providers on the following dates:

9/25/16
Day shift:
LVN 3 was assigned acute care patients and SNF residents.
Night shift:
LVN 4 was assigned acute care patients and SNF residents.

9/26/16:
Day shift:
LVN 3 was assigned acute care patients and SNF residents.
Night shift:
LVN 4 was assigned acute care patients and SNF residents.

9/27/16:
Day shift:
LVN 3 was assigned acute care patients and SNF residents.
Night shift:
LVN 4 was assigned acute care patients and SNF residents.

9/28/16:
Day shift:
LVN 5 was assigned acute care patients and SNF residents.
Night shift:
LVN 6 was assigned acute care patients and SNF residents.

9/29/16:
Day shift:
LVN 7 was assigned acute care patients and SNF residents.
Night shift:
LVN 8 was assigned acute care patients and SNF residents.

9/30/16:
Day shift:
LVN 9 was assigned acute care patients and SNF residents.
Night shift:
LVN 6 was assigned acute care patients and SNF residents.

10/1/16:
Day shift:
LVN 7 was assigned acute care patients and SNF residents.
Night shift:
LVN 8 was assigned acute care patients and SNF residents.

10/2/16
Day shift:
LVN 3 was assigned acute care patients and SNF residents.
Night shift:
LVN 4 was assigned acute care patients and SNF residents.

10/3/16
Day shift:
LVN 10 was assigned acute care patients and SNF residents.
Night shift:
LVN 4 was assigned acute care patients and SNF residents.

10/4/16
Day shift:
LVN 3 was assigned acute care patients and SNF residents.

10/5/16
Day shift:
LVN 3 was assigned acute care patients and SNF residents.
Night shift:
LVN 6 and Registered Nurse (RN) 7 were assigned acute care patients and SNF residents.

10/6/16
Day shift:
LVN 9 was assigned acute care patients and SNF residents.

Assistant Chief Nursing Officer (ACNO) was assigned acute care patients and SNF residents.

Night shift:
RN 8 was assigned acute care patients and SNF residents.
LVN 6 was assigned acute care patients and SNF residents.

10/7/16
Day shift:
LVN 5 and RN 6 were assigned acute care patients and SNF residents.
Night shift:
LVN 11 and RN 8 were assigned acute care patients and SNF residents.

10/8/16
Day shift:
LVN 5 and RN 5 were assigned acute care patients and SNF residents.
Night shift:
LVN 11 and RN 8 were assigned acute care patients and SNF residents.

10/9/16
Day shift:
LVN 5 and RN 5 were assigned acute care patients and SNF residents.
Night shift:
LVN 11 and RN 9 were assigned acute care patients and SNF residents.

10/10/16
Day shift:
LVN 2 and RN 6 were assigned acute care patients and SNF residents.
Night shift:
LVN 11 and RN 9 were assigned acute care patients and SNF residents.

10/11/16
Day shift:
LVN 3 and RN 6 were assigned acute care patients and SNF residents.

Policy and procedure requested for acute care staffing. No acute care staffing policy was provided by the hospital.

Based on staff interview, clinical record review and administrative document review, the hospital failed to develop interventions for nursing care plans when 17 of 30 patient charts (Patients 3,7,10-17, 19, 20, and 22- 26) did not contain interventions for nursing care plans.

This failure had the potential to place patients at risk of not having nursing care needs addressed and cause possible delays in treatment goals which could result in patient harm and/or prolonged hospitalization.

Findings:

On 10/11/16 at 9:10 a.m., during a concurrent interview and clinical record review of Patient 16, Clinical Manager (CM) 1 stated care plan interventions were not listed on the electronic record. She stated the nurse must free text (type into the clinical record) any intervention done. CM 1 stated nurses occasionally entered interventions in the patients' charts, but not consistently. She stated there was no way to know what interventions were done if the nurse did not hand write them into the clinical record. The clinical chart of Patient 13 was reviewed. CM 1 stated care plans for Patient 13 included Skin Integrity Related to Incision s/p (status post; after) surgery on Pressure Ulcer." CM 1 stated the care plan listed the problem and the goals, but did not offer any interventions. She stated the care plans were either "addressed" or "reviewed" by the nurses every shift, but interventions for the problems were only occasionally typed in by the assessing nurse. She stated addressed meant the nurse did something about the problem and reviewed meant the nurse read the plan of care. CM 1 stated those two options were the two most often used by the staff. She stated if the nurse did not type in an intervention, the only way an oncoming nurse would know how the problem was addressed was if it was passed on during the change of shift report from nurse to nurse.

On 10/11/16 at 9:45 a.m., during a concurrent interview and clinical record review, CM 1 stated care plans for Patient 14 included Skin Integrity. She stated the care plan was initiated on admit on 8/22/16 and was addressed every shift. She stated interventions were not entered in the care plan or in the nursing notes.

On 10/11/16 at 10 a.m., during a concurrent interview and record review, the clinical chart indicated Patient 3's care plan for "Alteration in Skin Integrity " lacked interventions. RN 1 verified Patient 3's care plan did not have interventions and stated care plans should have interventions.

On 10/11/16 at 10:20 a.m., during a concurrent interview and clinical record review, CM 1 stated a care plan titled, "Alteration in skin integrity" was initiated when Patient 15 was admitted on 10/5/16. She stated the care plan was updated or reviewed every shift, but no interventions were typed into the care plan.

On 10/11/16 at 11 a.m., during a concurrent interview and record review, the clinical chart indicated Patient 12's care plan "Alterations in Skin Integrity" lacked interventions. RN 1 verified Patient 12's care plan did not have interventions and stated care plans should have interventions.

On 10/11/16 at 3:15 p.m.. during an interview RN 3 stated the facility does not have a system in place that required nurses to enter interventions for care plans. It is not uncommon for care plans to lack interventions.

On 10/11/16 at 3:33 p.m., during an interview, RN 4 stated no interventions were listed in the clinical charts. She stated, "Sometimes on the computer we just 'address' the care plan, other times we type in interventions. There is no real consistency as far as this unit is concerned."

On 10/11/16 at 3:50 p.m. during a concurrent interview and record review, the clinical chart indicated Patient 26's care plan "Alteration in Skin Integrity" lacked interventions. RN 2 verified Patient 26's care plan did not have interventions. RN 2 stated the care plan did not provide guidance on how to achieve the goal because it did not have interventions.

On 10/11/16 at 3:53 p.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated, "Care plans are based on patient history and nursing assessment. Patient care plans and interventions are directed by patient needs and nursing experience." She stated a new nurse would not think of all the assessments an experienced nurse would.

On 10/12/16 at 9:30 a.m. during a record review, the clinical chart indicated Patient 11's care plan "Alteration in Skin Integrity" lacked interventions. Subsequent clinical chart review indicated, Patient 23, 24 and 25 care plan "Alteration in Skin Integrity" did not have interventions. RN 2 verified the clinical records did not have interventions for the care plans.

On 10/12/16 at 10:53 a.m., during an interview, RN 5 stated, "Sometimes I free text interventions, but not always. It depends on what I think the patient needs." She stated not all nurses apply the same interventions to the same problems.

On 10/13/16 at 8:45 a.m. during record review, the clinical chart indicated Patient 7's care plan, "Alteration in Skin Integrity" lacked interventions. Subsequent clinical chart review indicated Patient 10, 22 and 26's care plan "Alteration in Skin Integrity" did not have interventions. RN 2 verified the clinical records did not have interventions for the care plans.

On 10/13/16 at 9:40 a.m., during a concurrent interview and clinical record review, the Assistant Chief Nursing Officer (ACNO) stated Patient 17 was admitted on 9/23/16. She stated the care plan "Alteration in Skin Integrity related to Impaired Mobility" was initiated on admit. The ACNO stated no interventions were entered in the care plan or nurses notes. She stated interventions should be documented in the clinical record.

The hospital policy titled, "Assessment and Reassessment of Patients" dated 1/16 indicated "... Patients are reassessed to determine their response to treatment ... Scope of Assessments relative to medical and/or nursing interventions, effectiveness of interventions, resolution of patient problems/needs, and discharge preparation ... interdisciplinary team goals are adjusted based upon the changing needs of the patient and/or his response to prescribed interventions..."