HospitalInspections.org

Based on clinical record review and interview, it was determined the facility failed to develop interventions to achieve the documented goals of the care plans for 3 of 31 patients (Patient #12, #16 and #31). The three patients were admitted to the ICU (Intensive Care Unit). The failed practice had the potential to affect any patient admitted to the ICU. The findings follow:

A. Clinical record review revealed the following:
1) Patient #12 was admitted on 05/10/10. The patient's "Daily Goals Worksheets", dated 05/10/10 and 05/11/10, listed the goals to be accomplished but no interventions were documented as to how those goals were to be accomplished.
2) Patient #16 was admitted on 05/06/10. The patient's "Daily Goals Worksheets", dated 05/06/10, 05/07/10, and 05/08/10, listed the goals to be accomplished but no interventions were documented as to how those goals were to be accomplished.
3) Patient #31 was admitted on 05/12/10. The patient's "Daily Goals Worksheet", dated 05/12/10, listed the goals to be accomplished but no interventions were documented as to how those goals were to be accomplished.
B. The findings were confirmed in an interview with the Director of ICU on 05/13/10 at 1035.