HospitalInspections.org

Based on record reviews and interview, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failing to individualize the patient's nursing care plan to include all the patient's medical diagnoses for which the patient was being treated for 3 (Patient #1, Patient #2, Patient #3) of 5 sampled patient medical records reviewed for a nursing care plan.

Findings:

A review of the hospital policy titled "Plan of Care", provided by S2CCO as the most current policy, revealed in part: After a thorough nursing assessment is done, the care plans are completed by an RN. The care plan will identify the main problems or potential problems areas that are patient specific including interventions and measurable goals. The care plans are based on patient care needs and standards. The care plans will be individualized

A review of the current Patient #1's medical record revealed he was admitted on 9/25/15 with the following admit diagnoses: Stage IV sacral pressure ulcer and infected post-operative abdominal incision with a wound vac placement. A review further revealed that the patient ' s other medical diagnoses included in part; Atrial Fibrillation, Diabetes, Hypertension and Depression. A review of Patient #1's care plan revealed that Diabetes and Hypertension was not addressed as one of the patient's identified problems in his plan of care.

A review of the current Patient #2's medical record revealed she was admitted on 10/09/15 with the following admit diagnoses: post-operative surgical site infection to wound of the left hip/thigh, status post left hip open reduction internal fixation. A review further revealed that the patient ' s other medical diagnoses included in part: Diabetes, Hypertension, and Coronary Artery Disease. A review of Patient #2's care plan revealed Diabetes, Hypertension, and Coronary Artery Disease was not addressed as one of the patient's identified problems in her plan of care.

A review of the discharged Patient #3's closed medical record revealed he was admitted on 5/02/15 with the following admit diagnoses: Sepsis and Decubitus Ulcers to left hip and sacrum A review further revealed that the patient ' s other medical diagnoses included in part: Diabetes, Hypertension, and Bipolar Schizophrenia. A review of Patient #3's care plan revealed Diabetes, Hypertension, and Bipolar Schizophrenia was not addressed as one of the patient's identified problems in his plan of care.

In an interview on 11/04/15 at 3:30 p.m. with S2CCO, the above patient ' s care plans were reviewed. S2CCO indicated that the above referenced care plans were not inclusive. S2CCO further indicated that the care plans should have been comprehensive and included all of the patient ' s medical diagnoses and not solely those care needs related to the admitting diagnosis.