HospitalInspections.org
Bringing transparency to federal inspections
ENCOMPASS HEALTH REHABILITATION HOSPITAL OF DALLAS
DATA COLLECTION & ANALYSIS
Tag No.: A0273
Based on record review and interview, the facility failed to measure, analyze, and track quality indicators for trached patients admitted including trach dislodgments, in that,
Patient #5's record reflected a 3/30/18 incident which involved the patient trach coming out and having to be replaced. There was no incident report or quality review of the incident.
Findings included
Patient #5's electronic record reflected, "Progress Note-Nurse 3/30/18 10:47 AM...patient's trach had completely came out. I got it reinserted...color good...trach collar was not a proper fit and put another one on the patient..."
There was no incident report or quality review for the 3/30/18 trach dislodgement.
Patient #5's care plan was not updated with the 3/30/18 incident which involved the patient trach coming out and having to be replaced.
During an interview and record review on 4/17/18 ending at 10:00 AM, Personnel #1 was informed of the above findings. Personnel #1 confirmed the above findings.
NURSING CARE PLAN
Tag No.: A0396
Based on record review and interview, the facility failed to ensure that the nursing staff kept current, a nursing care plan for each patient, in that, Patient #5's care plan was not updated with the 3/30/18 incident which involved the patient trach coming out and having to be replaced.
Findings included
Patient #5's electronic record reflected, "Progress Note-Nurse 3/30/18 10:47 AM...patient's trach had completely came out. I got it reinserted...color good...trach collar was not a proper fit and put another one on the patient..."
Patient #5's care plan was not updated with the 3/30/18 incident which involved the patient trach coming out and having to be replaced.
During an interview and record review on 4/17/18 ending at 10:00 AM, Personnel #1 was asked about the Plan of care for Patient #5 and if it had been updated for the 3/30/18 trach dislodgement. Personnel #1 stated, "No ma'am." Personnel #1 was asked if the care plan addressed the comorbidities listed on the history and physical including sepsis prevention/cardiac/pancreatic mass/anxiety/and acute kidney injury. Personnel #1 stated, "No."
The 1/24/18 "Change in Condition" policy did not address updating the patient's care plan.