HospitalInspections.org

Based on observation, interview and record review, the hospital failed to develop individualized nursing care plans, with interventions/approaches, based on the patients' assessments for 2 of 13 sampled patients (Patient 3 and 9) in a universe of 51 patients. This failure had the potential to result in, the patients to not have received the care and treatment necessary to resolve identified health concerns based on their assessments.

Findings:

1. During a review of Patient 3's medical record on February 25, 2014, the record noted that the patient was admitted to the hospital on February 11, 2014 with a diagnosis of acute respiratory failure (fluid builds up in the air sacs in the lungs).
A review of the list of medications for Patient 3 noted a physician ' s order dated February 11, 2014 for morphine sulfate (pain medication) 2 milligrams to be given via IV (intravenous; through the vein) every four (4) hours on an as needed basis for moderate to severe pain (Moderate Pain - Interferes significantly with daily living activities; on a 1 to 10 pain scale with 10 as the most severe pain, moderate pain is rated 4 through 6. Severe Pain - Disabling; unable to perform daily living activities; severe pain is rated 6 through 10).
A review of the nursing patient care plans (a written plan directing the health care team with interventions and approaches of care to the patient) for Patient 3 noted that there was no individualized care plan developed for pain.

During an interview on February 25, 2014 at 10:45 AM with RN 2, RN 2 acknowledged that Patient 3 had received the prescribed pain medication several times and pain relieving interventions (distraction and repositioning ) during his hospitalization. RN 2 acknowledged that there was no active care plan in Patient 3's medical record to address the problems of pain and she stated that there should have been a care plan.

2. During a review of Patient 9's medical record on February 27, 2014, the record noted that the patient was admitted to the hospital on February 22, 2014 with a diagnosis of acute respiratory failure (fluid builds up in the air sacs in the lungs).
A review of the list of medications for Patient 3 noted a physician ' s order dated February 13, 2014 for Norco (a pain medication) 325 milligrams, one tablet, to be given via a feeding tube (a tube into the stomach) every four (4) hours on an as needed basis for pain.
A review of the nursing patient care plans for Patient 9 noted that there was no individualized care plan developed for pain.

During an interview on February 25, 2014 at 10:45 AM with RN 3, RN 3 acknowledged that Patient 9 had received the prescribed pain medication and pain relieving interventions (distraction and repositioning ) during her hospitalization. RN 3 acknowledged that there was no active care plan in Patient 9's medical record to address the problems of pain.

A review of a hospital ' s policy and procedure titled "Care Plan and Teaching Record, Multidisciplinary" with a revision date of August 2013, noted the following:

" Following the Patients ' initial assessment from each discipline a care plan will be initiated. Nursing typically opens the care plan during the first 24 hours of admission. The care plan is reviewed weekly by the multidisciplinary team. "

A review of a hospital ' s policy and procedure titled "Pain Management Plan" with an effective date of August 2013, noted the following:

" The registered nurse will develop a patient specific plan of care with the initial identification of patient pain; at the admission assessment and/or anytime during the patient ' s hospital stay. A licensed nurse involved in the care of the patient will update the patient specific plan of care as needed. "