HospitalInspections.org

Based on record review and interview, the nursing staff to develop and update an individualized plan of care for each patient. This deficient practice was evidenced by failing to update the care plan on 2 (#1, #2) of 3 (#1-#3) patients reviewed.
Findings:

A review of hospital policy titled "Multidisciplinary Treatment Plan," last revised January 2024, revealed in part: PROCEDURE: 1. An initial Care Plan/Problem List is developed within 8 hours of admission by the registered nurse that completes the Nursing Admission Assessment. This is considered the beginning of the MTP. 2. The Initial Care Plan should address the presenting problem and any high-risk behaviors at a minimum. 3. It is important for the registered nurse to include physical issues that require intervention during hospitalization, even if the problem is adequately managed (if the patient has hypertension, this should be addressed in the Initial Care Plan, even if medication keeps the pressure manageable). 10. The MTP will be updated as needed during hospitalization, to reflect such interventions as seclusion, a new medical illness, etc.

Review of Patient #1's medical record revealed Patient #1 was admitted on 07/31/2025 for Bipolar Disorder. On 08/03/2025, Patient #1 reported to the Provider she had bed bugs in her room and complained of an itchy rash noted to her neck, arms, hip, and legs, so the provider ordered Hydrocortisone cream for bed bugs, Elimite Cream for bed bugs, and Benadryl extra strength cream for bed bugs. Further review of Patient #1's medical record did not reveal an update to Patient #1's multidisciplinary treatment plan to reflect new diagnosis, medications and treatment.

Review of Patient #2's medical record revealed Patient #2 was admitted on 08/03/2025 for Depression. On 08/05/2025, Patient #2 reported to the Provider she had an itchy rash from bed bugs in her room, so the provider ordered Hydrocortisone cream for bed bugs, Elimite Cream for bed bugs, and Benadryl extra strength cream for bed bugs. Further review of Patient #2's medical record did not reveal an update to Patient #2's multidisciplinary treatment plan to reflect new diagnosis, medications, and treatment.

On 08/20/2025 at 11:30 AM S1DON verified the above information confirming patients' multidisciplinary treatment plans should be updated to reflect new diagnosis, treatment, and/or medications.