HospitalInspections.org

Based on document review and interview, it was determined that for 1 (Pt. #13) of 3 clinical records reviewed on the Mother/Baby unit for care plans, the Hospital failed to ensure a care plan was developed as required.

Findings include:

1. On 10/3/17 at approximately 11:00 AM, the policy entitled "Plan of Care Multidisciplinary Treatment Plan" (rev 1/2017), was reviewed and required "Procedure...2. The admitting nurse caring for the patient will start the multidisciplinary treatment plan by initiating the nursing plan of care within eight hours of admission to the unit... The plan of care should include goals, expected outcomes, interventions, evaluation and patient/family education relevant to the patient's problems..."

2. On 10/3/17 at approximately 10:00 AM, the clinical record for Pt. #13 was reviewed. Pt. #13 was a 30 year old female admitted on 9/30/17 with a diagnosis of planned cesarean. The clinical record lacked a plan of care.

3. On 10/3/17 at approximately 10:15 AM, the Charge Nurse (E #8) of the Mother/Baby unit was interviewed. E #8 stated, "The plan of care should be initiated on day of admission and updated as needed."

Based on document review and interview, it was determined that the Hospital failed to ensure a qualified physical therapist was available to provide the required services,which potentially affects 8 patients receiving physical therapy services.

Finding includes:

1. On 10/4/17, the "Mission and Scope of Services and Operational Functions of the Physical Therapy and Speech Therapy Programs" (rev. 1/2010) was reviewed and indicated " Physical Therapy:...Inpatients evaluations are normally completed within 24 hours of receipt of the physician order (except on some Saturdays, Sundays and holidays) and treatment is on-going daily until discharge..."

2. On 10/4/17 at approximately 1:30 PM, the Physical Therapist (E #12) was interviewed. E #12 stated that the Rehabilitation Department hours of operation are from 8:00 AM to 5:00 PM Monday through Friday. E #12 stated that she is the only physical therapist at the Hospital and works Monday thru Friday from 8:30 AM to 5:00 PM. Patients are not seen on weekends. E #12 stated that if she is on vacation or absent, the Hospital does not have a Physical Therapist to cover her absence. E #12 also stated that acute patients should be seen on a daily basis.