HospitalInspections.org

Based on record review and interview staff failed to develop nursing care plans that are comprehensive, individualized, and have measurable goals in 4 of 8 MR's reviewed (Pt 1, 4, 6, 7 ) and 2 of 2 staff interview (RN D,C).

Findings include:

Review on 5/21/15 of P/P titled, "Plan of Care" effective 1/20/2015 states the following:
-The purpose for this policy is to establish guidelines for providing individualized patient care that is multidisciplinary, consistent, coordinated, and high quality.
-The care plan for each individual patient shall be coordinated with the medical provider plan of care and will indicate what nursing care is needed and how it can be best achieved using evidence based practice.
- The care plan will include the identified patient problems, the goals to work toward, and the interventions to be used.
-The care plan is to be reviewed and updated daily if needed by RN.

Review on 5/21/15 beginning at 10:30 am of Pt 6's MR showed Pt 6 was admitted to the hospital on 4/30/15. Per review of Pt 6's Wound Care Status Report dated 5/1/15, 5/6/15, 5/13/15, and 5/19/15 Pt 6 was receiving treatment from the wound care RN for the following wounds: right heel diabetic ulcer, sacrum/coccyx pressure sore, right foot surgical wound, left heel diabetic ulcer, and right lower leg wound.

Review of Pt 6's Braden Scale (skin assessment tool) documented on 5/12/15 at 7:00 am and 7:00 PM shows Pt 6 is confined to bed and has very limited mobility, Pt 6's Braden Scale was scored at a 12 and 11 respectively. According to this scale, 10-12 is considered to be very high risk for skin breakdown.

Review of Pt 6's "Interdisciplinary Plan Of Care" shows a nursing diagnosis for "Impaired mobility", 2 preprinted goals are listed as "return to prior level of functioning" and "free from contractions" both goals are checked. Goals are not measurable or individualized to Pt 6's specific individual needs. Pt 6's care plan is only marked as reviewed by RN on 5/5/15 and 5/19/15 and not daily as per policy. Pt 6's MR shows no documentation providing evidence of RN performing specific interventions listed on Pt 6's Interdisciplinary Plan of Care or Pt 6's progression to meeting identified goals.

Review of Pt 6's Interdisciplinary Plan of Care also shows a nursing diagnosis for "Impaired Skin Integrity", boxes next to preprinted goals and interventions are all blank. There is no documentation in Pt 6's plan of care of RN developing measurable and individualized goals and identifying specific interventions for Pt 6's impaired skin integrity.

Review on 5/21/15 beginning at 12:00 pm of Pt 4's MR shows Pt 4 was admitted on 5/9/15. According to Pt 4's Wound Care Status Report dated 5/11/15, Pt 4 had multiple skin issues located on sacrum and coccyx, right lower leg, rash under abdominal folds, penis, left below the knee amputation site, abdominal surgical site, right foot, and right thigh.

Review of Pt 4's Braden Scale dated 5/11/15 shows patient was confined to bed and had very limited mobility, Pt 4's Braden Scale was scored at a 12; according to this scale 10-12 is considered to be very high risk for skin breakdown.

Review of Pt 4's "Interdisciplinary Plan of Care" shows a nursing diagnosis for "Impaired mobility", 2 goals are preprinted listed as "return to prior level of functioning" and "free from contractions" both goals are checked. Goals are not measurable or individualized to Pt 4's individual needs. Pt 4's care plan is only marked as reviewed by RN on 5/15/15, 5/19/15, and 5/20/15, not daily as per policy. Pt 4's MR shows no documentation providing evidence of RN performing specific interventions listed on Pt 4's Interdisciplinary Plan of Care and evaluating Pt 4's progression to meeting identified goals.

Review of Pt 4's Interdisciplinary Plan of Care also shows a nursing diagnosis for "Impaired Skin Integrity", 2 of the 3 preprinted goals listed are checked stating, "wound will not worsen during hospitalization" and "wound will improve during hospitalization". Goals are not measurable or individualized to Pt 4's specific needs. Pt 4's care plan is only marked as reviewed by RN on 5/15/15, 5/19/15, and 5/20/15, not daily as per policy. Pt 4's MR shows no daily documentation providing evidence of RN performing specific interventions listed on Pt 4's Interdisciplinary Plan of Care such as turning every 2 hours or evaluating Pt 4's progression to meeting identified goals.

Review of Pt 4's "Interdisciplinary Team Conference Assessment/Update" dated 5/20/15 shows that "Wound Healing" is checked as the "Weekly Team Goal"; this goal is not measurable or individualized to Pt 4's specific needs.

Review on 5/21/15 beginning at 12:50 pm of Pt 7's MR shows Pt 7 was admitted on 4/20/15. According to Pt 7's Wound Care Status Report dated 4/21/15, 4/29/15, 5/7/15, and 5/11/15 Pt 7 had skin issues located on sacrum and coccyx; on 4/21/15 Pt 7's sacral wound measured 1 x 1 cm on 5/11/15 Pt 7's sacral wound measured 5 x 5 cm. Per Wound Care RN documentation on 5/7/15 staff was to begin turning Pt 7 every hour side to side.
Review of Pt 7's Braden Scale dated 5/19/15 shows patient was confined to bed and had very limited mobility, Pt 7's Braden Scale was scored at a 12; according to this scale 10-12 is considered to be very high risk for skin breakdown.

Review of Pt 7's "Interdisciplinary Plan of Care" shows a nursing diagnosis for "Impaired mobility", 1 of 2 preprinted goal is checked stating "return to prior level of functioning". Goal is not measurable or individualized to Pt 7's individual needs. Pt 7's MR shows no daily documentation providing evidence of RN performing specific interventions listed on Pt 7's Interdisciplinary Plan of Care or evaluating Pt 7's progression to meeting identified goals.

Review of Pt 7's Interdisciplinary Plan of Care also shows a nursing diagnosis for "Impaired Skin Integrity", 3 of the 3 preprinted goals listed are checked stating, "patient's skin integrity will be maintained" and "Patient's decubitis/ulcer will not worsen during hospitalization" and "Patient's decubitus/ulcer will improve during hospitalization". Goals are not measurable or individualized to Pt 7's specific needs. Wound Care RN's updated intervention of turning Pt 7 every hour is not incorporated into Pt 7's Interdisciplinary Plan of Care. Pt 7's MR shows no documentation providing evidence of RN performing specific interventions of turning Pt 7 every hour and evaluating Pt 7's progression to meeting identified goals.


Review on 5/21/15 beginning at 1:25 pm of Pt 1's MR shows Pt 1 was admitted on 4/18/15. According to Pt 1's Wound Care Status Report dated 4/20/15, 4/27/15, 5/4/15, and 5/12/15 Pt 1 had skin issues located on sacrum and coccyx, right great toe, trachea site, peg tube site, and right and left axilla.

Review of Pt 1's Braden Scale dated 5/12/15 shows patient was confined to bed and had very limited mobility, Pt 1's Braden Scale was scored at a 12; according to this scale 10-12 is considered to be very high risk for skin breakdown. Review of Pt 1's "Interdisciplinary Plan of Care" shows a nursing diagnosis for "Impaired mobility", 2 of 2 preprinted goal our checked stating "return to prior level of functioning" and "Free from contractures". Goal is not measurable or individualized to Pt 1's individual needs. Pt 1's MR shows no daily documentation providing evidence of RN performing specific interventions done for Pt 1 to reach listed goals or evaluating Pt 1's progression to meeting identified goals.
Review of Pt 1's Interdisciplinary Plan of Care also shows a nursing diagnosis for "Impaired Skin Integrity", 2 of the 3 preprinted goals listed are checked stating, "patient's skin integrity will be maintained" and "Patient's decubitis/ulcer will not worsen during hospitalization". Goals are not measurable or individualized to Pt 1's specific needs. Only one preprinted intervention on Pt 1's POC is checked (Wound care per orders). Pt 1's MR shows no comprehensive documentation of a RN developing and providing specific interventions to meet identified goals.

Per interview with RN C and RN D on 5/21/15 at 10:35 am, RN should document and updating POC daily and care plan should be individualized and complete.

Shared above findings with RN C and RN D on 5/21/15 beginning at 3:00 pm.

Based on record review and interview staff failed to ensure all intervention provided to patients are documented in the medical record in 8 of 8 medical records (Pt 1,2,3,4,5,6,7,8) and 2 of 2 staff interviews (RN D, C).


Findings include:

Review on 5/21/15 of P/P titled, "Guidelines For Nursing Care" effective 2/20/2015 states, all bedfast patients should be turned every 2 hours and this should be documented.

Review on 5/21/15 of P/P titled, "Skincare Prevention" no revision date states, patients who are high risk for skin break down (Braden scale of 6-12) should have skin inspected every 2-4 hours for signs and symptoms of breakdown. Establish and record an individualized turning schedule if the patient is immobile, frequency of position change is titrated for the individual patient. Evaluate the skin after each turning; if there is non-blancable redness increase the frequency of turning.

Per interview with RN D and RN C on 5/21/15 beginning at 10:35 am, staff do not document in the MR every time a patient is turned or a skin assessment every 2-4 hours for patients with a high risk for skin breakdown. Staff just document the plan to turn every 2 hours under the "activity" category in daily nursing assessment documentation.

Review on 5/21/15 beginning at 10:30 am of MR's for Pt 1, 2, 3, 4, 5, 6, 7, 8 shows all patients to have high risk for skin breakdown and an intervention listed to be turned every 2 hours. No documentation in MR's showing evidence of staff turning patients every 2 hours and performing skin assessments every 2-4 hours for the patients with a very high risk for skin breakdown.