HospitalInspections.org

Based on hospital policy, medical record review and interview, the hospital failed to ensure plans of care were individualized and addressed all the identified patient care needs for 2 of 3 ( Patient #2 and 3) sampled patients.

The findings included:

1. Review of the hospital policy "Care Planning" revealed, "...It is the policy of the hospital that each patient admitted will have and IPOC [Interdisciplinary Plan of Care] developed, which will be based on his/her assessed individual needs...physical, cognitive and functional impairments and co-morbid conditions...Each body system or functional area will be followed by specific interventions designed to meet the need of the patient..."

2. Medical record review for Patient #2 revealed an admission date of 1/25/18 with diagnoses that included Recurrent multifocal ischemic strokes, Chronic Obstructive Pulmonary Disease and Hypertension. The nursing assessment completed on 1/25/18 documented he was incontinent of bladder and bowel. The medical record review revealed Patient #2 consistently wore incontinent briefs due to bladder and bowel incontinence. Review of the IPOC dated 1/25/18 did not address the problem of incontinence.

In an interview on 4/4/18 at 2:10 PM, the Chief Nursing Officer and Director of Quality verified the IPOC did not address Patient #2's incontinence needs.

3. Medical record review for Patient #3 revealed an admission date of 3/22/18 with diagnoses that included Metabolic encephalopathy associated with community acquired pneumonia. The nursing assessment completed on 3/22/18 documented he was incontinent of bladder. The medical record review revealed Patient #3 at times wore incontinent briefs due to bladder incontinence and that he had a condom catheter due to his incontinence. Review of the IPOC dated 3/22/18 did not address the problem of incontinence.


In an interview on 4/4/18 at 12:05 PM, the Director of Quality verified the IPOC did not address Patient #3's incontinence needs.

Based on medical record review and interview, the hospital staff failed to ensure there were documented and signed orders by the practitioner responsible for the care of the patient for the use of a condom catheter for 1 of 2 (Patient #3) patient reviewed for incontinence .

The findings included:

1. Medical record review for Patient #3 revealed an admission date of 3/22/18 with diagnoses that included Metabolic encephalopathy associated with community acquired pneumonia. The medial record documented he had a condom catheter on 3/22/18 through 3/27/18. There was no physican order for the condom catheter.

2. In an interview on 4/4/18 at 12:20 PM, the Chief Nursing Officer verified there should have been a physican order prior to the condom catheter placement.

Based on medical record review and interview the hospital failed to ensure all patient medical record entries were complete and contained sufficient nursing documentation for the course of care and treatment for 2 of 2 (Patient #1 and 2) sampled patients with pressure sores.

The findings included:

1. Medical record review for Patient #1 revealed an admission date of 3/29/18 with diagnoses that included Bilateral Pneumonia. On 3/29/18 the Wound Care Coordinator documented he had a Stage 1 pressure ulcer to his right heel. Physician orders dated 3/29/18 revealed "Float Heels".

There was no nursing documentation that Patient #1's heels were floated as ordered by his physician.

In an interview on 4/4/18 at 11:20 AM, the Chief Nursing Officer verified there was no nursing documentation in the medical record for floating the heels of Patient #1.

2. Medical record review for Patient #2 revealed an admission date of 1/25/18 with diagnoses that included Recurrent multifocal ischemic strokes, Chronic Obstructive Pulmonary Disease and Hypertension. He was discharged from the hospital on 2/17/18. Physican orders dated 1/29/18 revealed "Place foam dressing to sacral area. Gently lift foam daily dressing and inspect skin..."

There was no nursing documentation on 2/13/18 and 2/14/18 that the foam dressing was checked as ordered by the physican.