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PAM REHABILITATION HOSPITAL OF BEAUMONT
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview the facility failed to complete a physical assessment of 1 of 1 patients receiving rehabilitation services.
On 9/26/2012 the medical record (MR) for patient (pt) #1 was reviewed and revealed that there was a physician's order for hot packs provided by physical therapy (PT) but there was not a focused nursing assessment located in the chart to correspond with the daily hot packs applied to the patients' back while in PT.
A review of facility policy S.O.P. #8300.105 reads as follows:
Professional Nursing shall be defined as the performance for compensation by any nursing act:
1.a. in the observation, assessment, intervention, evaluation, rehabilitation, care and counsel and health teachings of persons who are ill, injured, infirm, or experiencing changes in their normal health processes;
3. The Department of Nursing shall develop a Rehabilitation Nursing Philosophy evaluating and improving the quality of nursing care provided at HealthSouth Rehabilitation Hospital;
4. The Department of Nursing shall develop standards and mechanisms for Evaluating and improving the quality of nursing care provided at HealthSouth Rehabilitation Hospital;
5. The Department Nursing shall develop mechanisms to define and evaluate nursing care provided in all departments of HealthSouth Rehabilitation Hospital.
An interview with staff #1 confirmed that communications between PT and nursing was identified as needing more interdisciplinary communications. PT was not communicating to the nursing staff what interventions they were using to facility the patient's ability to participate in ambulation therapy or other therapy goals (hot packs for chronic pain management). The nursing staff was not assessing the patient after PT for the location of the pain, pain management during PT,or extended pain control after PT.
NURSING CARE PLAN
Tag No.: A0396
Based on document review the facility failed to develop a care plan for pain management for 1 of 1 patients reviewed.
Onn 9/26/2012 a review of pt #1 Medical Record (MR) revealed there was no care planning for pain managment identified in the nursing care plan. Physician documentation revealed doctors orders for Mobic to be taken orally as an anti arthritic medication, lidoderm patch as topic pain analgesia and hot packs to be applied the the patient's back in Physical therapy.
An interview with staff #6 confirmed no problem was identified for pain managment in the patient's care plan.