HospitalInspections.org

Based on record reviews, staff interviews and review of facility policy and procedure, the facility failed to develop a plan of care for 1 of 30 sampled patients (Patient 5) and failed to keep current a plan of care for 1 of 30 sampled patients (Patient 16). The total sample size was 30. Facility census was 309. Findings are:

A. Medical record review on 5/1/13 at 11:00 AM revealed Patient 5 was admitted to Labor and Delivery on 4/29/13. After a normal vaginal delivery on 4/29/13 the patient suddenly stopped breathing and had a seizure while in the delivery room. The patient was intubated and transferred immediately to the Intensive Care Unit. Review of the patient's record failed to find a Plan of Care for this patient.

Staff interview with the Obstetrics Nursing Manager on 5/1/13 at 12:15 PM confirmed after reviewing the record that the staff failed to develop a Plan of Care for this patient.

B. Review of the facility policy titled "Care Plans (Standards of Care) " effective 8/2/11, revealed staff Registered Nurses (RNs) "insures that all appropriate follow-up actions have been activated, and determines the priority nursing diagnoses/patient needs. 1. The appropriate Population Specific Care Plan will be placed on the patient's chart and/or clipboard within 8 hours of admission or with a change in the patient's condition. When an appropriate Care Plan does not exist for a patient, the RN creates an individualized Care Plan on the Care Plan template."

Under the section titled "B. Ongoing Care Plan Documentation" the policy states that "The Plan of Care is reviewed/identified a minimum of every shift. Patient progress towards goals/outcomes will be documented at least once a shift."


16132


C. Record review of the medical record for Patient 16 revealed the lack of a Care Plan for safety interventions following a LeFort 1 Jaw Surgery (a surgical operation where the jaw bone is cut to shorten or change the bone alignment) requiring reconstruction of jaw resulting in the wiring of the jaw shut.

Review of the Physician Orders for Patient 16 on 5/1/13 and 5/2/13 revealed:
- Osteotomy-Sagittal Split/LeFort (Surgical cutting of the jaw bone): Wire cutters with patient at all times. Flashlight/penlight, tongue blades. Pourable Full Liquids/pureed diet. No blowing nose and No straws. Oral suction at bedside PRN (as needed). Instruct and assist patient with oral care. Use a child-sized toothbrush.

Review of the Plan of Care for Patient 16 revealed only a Plan of Care for Pain management.

Interview with the Nurse Manager (RN-A) on 5/1/13 at 4:15 PM verified that Patient 16's record only had a Plan of Care for Pain and lacked any Plan of Care related to the issue of the jaw being wired and the procedures/interventions associated with the changes in the patient's care.

Based on record reviews, staff interviews and review of facility policy and procedure, the facility failed to develop a plan of care for 1 of 30 sampled patients (Patient 5) and failed to keep current a plan of care for 1 of 30 sampled patients (Patient 16). The total sample size was 30. Facility census was 309. Findings are:

A. Medical record review on 5/1/13 at 11:00 AM revealed Patient 5 was admitted to Labor and Delivery on 4/29/13. After a normal vaginal delivery on 4/29/13 the patient suddenly stopped breathing and had a seizure while in the delivery room. The patient was intubated and transferred immediately to the Intensive Care Unit. Review of the patient's record failed to find a Plan of Care for this patient.

Staff interview with the Obstetrics Nursing Manager on 5/1/13 at 12:15 PM confirmed after reviewing the record that the staff failed to develop a Plan of Care for this patient.

B. Review of the facility policy titled "Care Plans (Standards of Care) " effective 8/2/11, revealed staff Registered Nurses (RNs) "insures that all appropriate follow-up actions have been activated, and determines the priority nursing diagnoses/patient needs. 1. The appropriate Population Specific Care Plan will be placed on the patient's chart and/or clipboard within 8 hours of admission or with a change in the patient's condition. When an appropriate Care Plan does not exist for a patient, the RN creates an individualized Care Plan on the Care Plan template."

Under the section titled "B. Ongoing Care Plan Documentation" the policy states that "The Plan of Care is reviewed/identified a minimum of every shift. Patient progress towards goals/outcomes will be documented at least once a shift."


16132


C. Record review of the medical record for Patient 16 revealed the lack of a Care Plan for safety interventions following a LeFort 1 Jaw Surgery (a surgical operation where the jaw bone is cut to shorten or change the bone alignment) requiring reconstruction of jaw resulting in the wiring of the jaw shut.

Review of the Physician Orders for Patient 16 on 5/1/13 and 5/2/13 revealed:
- Osteotomy-Sagittal Split/LeFort (Surgical cutting of the jaw bone): Wire cutters with patient at all times. Flashlight/penlight, tongue blades. Pourable Full Liquids/pureed diet. No blowing nose and No straws. Oral suction at bedside PRN (as needed). Instruct and assist patient with oral care. Use a child-sized toothbrush.

Review of the Plan of Care for Patient 16 revealed only a Plan of Care for Pain management.

Interview with the Nurse Manager (RN-A) on 5/1/13 at 4:15 PM verified that Patient 16's record only had a Plan of Care for Pain and lacked any Plan of Care related to the issue of the jaw being wired and the procedures/interventions associated with the changes in the patient's care.