HospitalInspections.org

Based on chart reviews, interviews, and policy and procedures the facility failed to follow their own policy and procedures to ensure the patient received a copy of their patient rights upon admission in 8 (#1, #2, #3, #5, #7, #9, #12, and #13) out of 13(1-13) charts reviewed.

Review of the facility's policy and procedure, "A Statement on Patient's Rights" stated, " #17 Receive at the time of admission, information about the hospital's patient rights policies, mechanism for the initiation, review,and when possible resolution of patient complaints concerning the quality of care."

Review of patient chart #1, #2, #3, #5, #7, #9, #12, #13, revealed the "Patient Authorization Form" was incomplete. The section marked Patient Rights and Responsibilities which stated "I have received a copy of the Patient Rights and Responsibilities as included in the brochure "Important Patient Information", was left blank.

Interview with staff #1 and #2 confirmed the consents were left blank on "received Patient Rights". Staff #2 stated, "I will be sure to go over this with the nurses to prevent this from happening again."

Based on chart reviews, interviews, and policy and procedures the facility failed to follow it's own policy and procedures to ensure each patient had a care plan initiated on admission, care plan was unique, kept current and ongoing, and involved multidisciplinary tools to reflect the goals and therapies of other disciplines in 6 (#2, 1, 6, 5, 7, 3) out of 6 (#2, 1, 6, 5, 7, 3) charts reviewed.

Review of the policy and procedure "Patient Plan of Care" stated, " POLICY: 3.1 A plan of care will be initiated within 24 hours of admission for all inpatient admissions to respond to each patient's unique needs.

3.6 The nursing care planning starts upon admission. The nursing care plan is kept current by ongoing assessment of the patient's needs and the patient's response to interventions, and updating or revising the patient's care plan in response to assessments.

3.8 The plan of care is a multidisciplinary tool and should reflect the goals and therapies of other disciplines.

4.3 Patient problems/needs should be evaluated and prioritized on a daily basis, and revised and reprioritized as the patient's condition warrants."


Review of patient #2's chart revealed patient #2 was admitted on 10/29/2014. Patient #2's history and physical revealed the following, "56 y.o female admitted by intensivist on 10/22/14 due to acute respiratory failure s/p on MV ,- since here has been found with multiple medical condition including aki, acute PE and is currently on heparin and will be transitioned to xarelto , Cdiff- she is now off MV but is requiring BIPAP- will admit to TCC as will need rehab and cont tx here -at exam time was calm and vss- of note she was septic and required levophed also with ams change that has resolved."

Review of patient #2's nursing care plan revealed two entries. The entries revealed the following:

1. On 11/20/2014 Problem: Pressure Ulcer
Goal: Decrease in pressure ulcer size.
Outcome: Improved.

2. On 11/24/2014 Problem: Tissue Perfusion Alteration
Goal: Improve- Tissue Perfusion Alteration
change in or modification of the oxygenation of tissues.
Outcome: Improved

2.A. Problem : Urinary Retention
Goal: Improve-Urinary retention
Incomplete emptying of the bladder.
Outcome: Completed Date Met: 1/24/14

Patient #2's care plan was not initiated on admission and was not kept current or ongoing.

Review of patient #1's chart revealed patient #1 was admitted on 8/11/2013 and discharged 9/28/2013. There was no nursing care plan found in the medical record.

Review of patient #6's chart revealed patient #6 was admitted on 10/20/2014 and discharged 12/01/2014 initial care plan was started on 11/10/2014 the following problems were found;

Problem: Admission - General, Adult
Goal: Oriented to hospital environment and policies
Outcome: Completed Date Met: 11/10/14

Problem: Falls - Risk of
Goal: Absence of falls
PERFORMANCE MEASURE.
Outcome: Progressing
No noted falls. Fall precautions reinforced with pt with good understanding. No c/o dizziness when ambulating.
Ambulates per self in room.

Problem: Infection - Risk of, Central Venous Catheter-Associated Bloodstream Infection
Goal: Absence of infection signs and symptoms
PERFORMANCE MEASURE.
Outcome: Progressing
Giving antibiotics as ordered. Pt afebrile. Labs being monitored.

Problem: Nutrition Deficit
Goal: Adequate nutritional intake
Outcome: Progressing
Appetite good. Needs encouragement to drink fluids. No nausea or GI symptoms

Patient #6's care plan was not initiated on admission and was not kept current or ongoing, with measurable goals, nursing interventions, or promote collaboration between members of the health care team.

Review of patient #5's chart revealed patient #5 was admitted on 9/26/2014 and discharged 10/15/2014. There was no nursing care plan found in the medical record.

Review of patient #7's chart revealed patient #7 was admitted on 02/17/2015. The care plan found revealed the following;

Problem: Medical Milestone
Goal: Goal 1 of the Day
Generated by 2171 at 2/26/15 4:41
What will we focus on today to get the patient closer to meeting his/her Medical Milestone(s)?
Outcome: Improved
Stayed WNL

Patient #7's care plan was not initiated on admission and was not kept current or ongoing, with measurable goals, nursing interventions, or promote collaboration between members of the health care team.

Review of patient #3's chart revealed patient #3 was admitted on 02/22/2015. There was no nursing care plan found in the medical record.

Interview with staff #1, #2, and #4 confirmed the care plans were incomplete or absent from the chart. Staff #2 stated, " I will have to do some more education on the care plans."