HospitalInspections.org

Based on interview and record review the hospital failed to keep care plans current for 6 of 6 records reviewed of patients suffering falls out of a total sample of 10.

Findings include:

On 6-27-12 at 10:45 AM the following P&P was reviewed.

P&P titled Plan of Care- Individualized and Interdisciplinary was reviewed. The P&P stated in part, " Each patient ' s individualized and interdisciplinary plan of care is appropriate to the patient ' s individualized assessed needs, strengths, limitations and goals. The care and treatment are provided according to the plan by an interdisciplinary team, lead by a physician. The individualized plan of care is reviewed and revised based on the patient ' s response to treatment.

III. The plan is continuously evaluated and monitored for effectiveness in meeting its intended goals at team conferences, with updates or modifications a minimum of weekly or as necessary to monitor:

B. Modifications are made to the plan of care and resource allocations are made based on reassessment of the patient at specific intervals and related to the following elements:
1. Progress toward goals
2. Failure to make progress
3. Unusual response to treatment
4. Failure to participate
5. Other significant data
6. Emergent issues

On 6-27-12 at 11:04 AM an interview with LPN E was completed. LPN E explained the nursing care plan should be changed with each fall and include an assessment of the reason for falling. LPN E stated this assessment is completed by the team which includes therapy, nursing, and a physician. LPN E explained if a patient falls, nursing is expected to assess the patient, call the doctor, and the family. LPN E stated the charge nurse for the shift is responsible to update the care plan.

On 6-27-12 at 9:06 AM a review of the medical record for patient (pt.) #2 was completed. The record showed pt. #2 was admitted on 3-21-12 with a diagnosis of Stroke and discharged on 3-30-12. The pre-admission assessment dated 3-20-12 states in part, " Safety precaution details- High fall risk, decreased balance, cognitive impairment, bed alarm, chair alarm, do not leave alone in bathroom, one-to-one supervision. " Documentation shows pt. #2 fell on 3-23-12, 3-25-12, and 3-28-12. The plan of care states in part on 3-21-12, "Patient will remain free from falls". The plan of care was not updated after the falls on 3-23-12, 3-25-12, and 3-28-126-1-12. The Morse Fall Scale was not completed after the falls.

On 6-28-12 at 9:20 AM the record for pt. #8 was reviewed. Pt. #8 was admitted on 5-31-12 and discharged home on 6-6-12. Nursing documentation on 6-1-12 show pt. #8 fell. The plan of care states in part on 5-31-12, "Patient will remain free from falls". The plan of care was not updated after the fall on 6-1-12. The Morse Fall Scale was not completed after the falls.

On 6-28-12 at 10:20 AM the record for pt. #9 was reviewed. Pt. #9 was admitted on 6-7-12 and discharged on 6-13-12 to an acute unit of another facility. The admitting diagnosis was Paraplegia. Nursing documentation on 6-8-12 and 6-13-12 show pt. #9 fell. The plan of care states in part on 6-7-12, "Patient will remain free from falls". Estimated completion date 6-21-12. The plan of care was not updated after the falls on 6-8-12 and 6-13-12. The Morse Fall Scale was not completed after the falls.

On 6-28-12 at 11:52 AM the record for pt. #10 was completed. Pt. #10 was admitted on 5-7-12 and discharged on 6-22-12. Documentation shows pt. #10 suffered a fall on 6-9-12. The nursing admission assessment dated 5-7-12 states in part, under "Precautions and special needs - High fall risk". The plan of care does not address safety, high fall risk, nor was it updated after the fall on 6-9-12. The Morse Fall Scale was not completed at admission.

On 6-28-12 at 12:35 PM the record for pt. #11 was completed. Pt. #11 was admitted on 5-29-12 and discharged on 6-16-12. Documentation shows pt. #11 suffered a fall on 6-12-12. The plan of care states in part on 5-29-12, "Patient will remain free from falls". Estimated completion date 6-12-12. The plan of care was not updated. The Morse Fall Scale was not completed after the fall.

On 6-28-12 at 12:15 PM at 12:15 PM the record for pt. #12 was completed. The record shows pt. #12 was admitted on 6-9-12 and fell on 6-26-12. The record shows pt. #12 did not receive another MORSE Fall scale assessment to aid in updating the plan of care. The plan of care states in part on 6-9-12 "Patient will remain free from falls". Estimated completion date 6-23-12. The plan of care was not updated.

On 6-28-12 at 12:31 PM the above findings were reviewed and confirmed by Director of Quality A.