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Based on record review and interview, the facility failed to ensure a current and up-to-date nursing care plan for Patient #1 (P #1). The facility failed to ensure P #1 medical record had a current and up-to-date nursing care plan.


Findings:


Review of P #1 medical record revealed the patient was admitted on 4/24/19.

Review of P#1 Patient Care Record, dated 5/3/19 revealed at 18:30, "a small skin tear noted to left shoulder of unknown origin, pt denies pain, charge nurse made aware, covered with dressing".

Further review of the record, revealed there was no documentation the patient's physician was notified. Nor was there documentation of the skin tear being monitored or cared for by the nursing staff.


Further review of the patient's medical record revealed the nursing care plan, created 4/24/19, was not updated nor reviewed for the skin tear discovred on 5/3/19.


Interview on 6/4/19 with facility staff #1 confirmed the above findings.