HospitalInspections.org

Based on document review and interview the facility failed to ensure nursing staff maintained an updated plan of care (POC) for 7 out of 10 patients (#1,#2,#3,#6,#8,#9,#10) resulting in the potential for ineffective care.

Findings include:

On 2/18/14 at approximately 1135, review of patient # 3's medical record revealed incomplete documentation on the documents titled "24 Hour Patient Record & POC" and "Wound Documentation." Patient #3 was admitted on 2/8/14 for acute respiratory failure. Wound care orders included an order to change dressing every other day for the abdominal wound. The Wound Documentation form revealed no documentation for the dates of 2/14/14 and 2/15/14. Review of the 24 hour Patient Record & POC for 2/13/14-2/16/14 revealed multiple sections lacking complete nursing assessment documentation including "Cardiac", "Gastrointestinal (GI)", "Mobility", and "Nutrition."

On 2/19/14 at approximately 0900 review of patient #6's medical record revealed incomplete nursing assessment documentation on the document titled "24 Hour Patient Record & POC." Patient #6 was admitted on 12/23/13 for cellulitis and multiple large wounds. On the "24 Hour Patient Record and POC" with date range from 1/14/14-1/18/14 several sections were lacking complete nursing assessment documentation including "Cardiac", "Integumentary", and "Mobility."

On 2/19/14 at approximately 1040 review of patient #8's medical record revealed incomplete documentation on the documents titled "24 Hour Patient Record & POC" and "Wound Documentation". Patient #8 was admitted on 2/14/14 for respiratory failure and multiple wounds. Wound care orders included daily dressing changes for wounds located on the right low axilla, right upper thorax, right anterior upper thigh, and right median line axilla. Review of the "Wound Documentation" form revealed no documentation for 2/16/14 and 2/17/14 on the right low axilla wound, no documentation for 2/17/14 and 2/18/14 for the right upper thorax wound, no documentation for 2/16/14 and 2/17/14 for the right anterior upper thigh wound, and no documentation for 2/16/14, 2/17/14, and 2/18/14 for the right median line axilla wound. On the "24 Hour Patient Record and POC" for 2/14/14 and 2/16/14 the "Mobility" section was lacking documentation.

On 2/19/14 at approximately 1120 review of patient #9's medical record revealed incomplete documentation on the documents titled "24 Hour Patient Record & POC" and "Wound Documentation". Patient #9 was admitted on 2/10/14 with ventilator dependent respiratory failure. Wound care orders included a daily dressing change for the patient's sacral wound. Review of the "Wound Documentation" form revealed no documentation for 2/13/14, 2/14/14, and 2/15/14. On the "24 Hour Patient Record and POC" for 2/16/14, 2/17/14, and 2/18/14 several sections were lacking documentation of a complete nursing assessment including "Cardiac", "GI", "Mobility", and "Nutrition."

During an interview on 2/19/14 at approximately 1215, Staff A was queried regarding the incomplete documentation for patients #3, #6, #8, and #9 to which he replied, "I agree the documentation is incomplete, we should be documenting on here." Staff A was also queried as to the missing days of wound documentation to which he replied "Yes, it appears documentation is missing for those days and that is not acceptable."




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On 2/18/14 at approximately 1100, review of patient #1's medical record revealed incomplete nursing assessment documentation on the documents titled, "24 hour patient record & POC" and "Wound Documentation." Patient #1 was admitted on 2/14/14 for ventilator dependent respiratory failure (VDRF). Wound care documentation was ordered for daily skin breakdown observation. Documentation was completed on 2/14/14, the day of admit. The dates 2/15/14-2/17/14 did not have wound care documentation as ordered. On the "24 hour patient record and POC" for 2/15/14 and 2/16/14 multiple sections were lacking complete nursing assessment documentation including "Pulmonary", "Genitalia/Urinary" (GU) and "Mobility." On 2/17/14 there was not complete nursing assessment documentation for the "Pulmonary", "GU", "Integumentary" and "Mobility". These findings were confirmed on 2/18/14 at approximately 1120 by Staff B.

On 2/18/14 at approximately 1300, review of patient #2's medical record revealed incomplete nursing assessment documentation on the document titled, "24 hour patient record & POC." Patient #2 was admitted on 2/11/14 for wound care, nutrition and physical/occupational therapy. On the "24 hour patient record and POC" for 2/12/14-2/17/14 multiple sections were lacking complete nursing assessment documentation including "Genitalia/Urinary (GU)", "Integumentary" and "Mobility". These findings were confirmed on 2/18/14 at approximately 1320 by Staff B.

On 2/19/14 at approximately 1000, review of patient #10's medical record revealed incomplete nursing assessment documentation on the documents titled, "24 hour patient record & POC." Patient #10 was admitted on 2/01/14 for ventilator dependent respiratory failure (VDRF). On the "24 hour patient record and POC" for 2/16/14 - 2/18/14 multiple sections were lacking complete nursing assessment documentation including "Genitalia/Urinary (GU)" and "Mobility."

On 2/19/14 at approximately 1300, during an interview with staff A, he was queried as to if there was anywhere else documentation for patient #10's POC might be located, for which he replied, "No."

On 2/20/14 at approximately 0900, during policy and procedure review, it was found in the policy titled, "Assessment and Reassessments of Patients", with the revision date of, 04/01/12, states under the section, "Scope of Assessment by Nursing", "Reassessment is a documented description of the patient's response/status relative to medical and/or nursing interventions, effectiveness of interventions, resolution of patient problems/needs, and discharge preparation. All data collected on patients is reviewed and analyzed by the RN assigned to oversee care for the patient; interdisciplinary team goals are adjusted based upon the changing needs of the patient and/or his response to prescribed interventions. Reassessment is documented approximately every twelve (12) hours and when the patient's condition warrants."