HospitalInspections.org

Based on record review and interview, the facility failed to ensure that individualized nursing care plans were developed based on patient's needs assessments to determine patient care issues and diagnoses in 8 of 10 medical records (Patient (Pt.) #1, 2, 3, 5, 6, 8, 9, 10), in a total sample of 10 medical records reviewed.

Findings Include:

A review of facility policy, titled "Nursing Care Plan", date reviewed 04/2023, revealed: "PURPOSE...ensuring that patient goals and care plans are...individualized...II. Nursing Diagnosis A. The nurse will analyze the assessment data to determine patient-focused care issues/Nursing Diagnoses. B. The nurse will prioritize and document diagnoses to be addressed in the Nursing Care Plan..."

A review of Pt. #1's medical record, revealed: A 16-year-old female admitted 10/23/2023 - 06/06/2024 status post motor vehicle accident with Traumatic Brain Injury (TBI) and Chronic Respiratory Failure. Past medical history included: Trach (tracheostomy) was placed on 08/21/2023, and a foley catheter on admission for bladder incontinence. Pt. #1's Nursing Care Plan did not address the patient's diagnoses related to Trach and foley catheter care.

During an interview on 08/06/2024 at 1:33 PM with CNO D, when asked what the Nursing Care Plan expectation is for patients with a tracheostomy and foley catheter, CNO D stated "Ideally we'd expect to see those reflected on Care Plans."

A review of Pt. #2's medical record, revealed: A 70-year-old female that is a current inpatient, was admitted on 05/17/2024 for Chronic Respiratory Failure with Chronic Pneumonia. Past medical history included: Trach and PEG (tube feeding) was in place on admission. Pt. #2's Nursing Care Plan did not address the patient's diagnoses related to Trach or PEG tube feedings.

During an interview on 08/06/2024 at 3:40 PM with CNO D, when asked what the Nursing Care Plan expectation is for patients with a PEG, CNO D stated "I would like to see them in the Care Plans."

A review of Pt. #3's medical record, revealed: A 67-year-old male that is a current inpatient, was admitted on 06/15/2024 for Acute on Chronic Hypoxic Respiratory Failure. Past medical history included: A chronic foley catheter in place for recurrent UTI (urinary tract infection) and urinary incontinence, Congestive Heart Failure (CHF) and Diabetes. Pt. #3's Nursing Care Plan did not address the patient's diagnoses related to foley catheter, CHF and Diabetes. Confirmed during interview with CNO D at the time of review on 08/06/2024 at 3:45 PM.

A review of Patient #5's medical record, revealed: A 58-year-old male admitted 03/19/2024 - 04/26/2024 for TBI with SHD (subdural hematoma) status post craniotomy (surgical opening into the skull). Past medical history included: Seizures (on anti-seizure medication) and a PEG was placed to provide nutritional support. Pt. #5's Nursing Care Plan did not address the patient's diagnoses related to Seizures and PEG tube feedings. Confirmed during interview with CNO D at the time of review on 08/06/2024 at 4:30 PM.

A review of Patient #6's medical record, revealed: A 18-year-old female admitted 06/21/2024 - 07/16/2024 for TBI due to motor vehicle accident. Past medical history included: Chronic Respiratory Failure with Tracheostomy tube and PEG tube for tube feedings, both placed on 06/10/2024. Pt. #6's Nursing Care Plan did not address the patient's diagnoses related to Tracheostomy and PEG tube feedings. Confirmed during interview with Quality Coordinator C at the time of review on 08/07/2024 at 9:42 AM.

A review of Patient #8's medical record, revealed: A 75-year-old male admitted 07/08/2024 - 07/24/2024 for TBI due to motor vehicle accident. Past medical history included: Bilateral hearing aides for hearing loss and Anorexia due to poor appetite but able to eat with encouragement. Pt. #8's Nursing Care Plan did not address the patient's diagnoses related to auditory impairment and eating disorder. Confirmed during interview with CNO D at the time of review on 08/07/2024 at 10:25 AM.

A review of Patient #9's medical record, revealed: A 34-year-old female admitted 05/10/2024 - 06/21/2024 for Deep Tissue Infection status post right thigh incision and debridement (removal of damaged tissue). Past medical history included: IV (intravenous) antibiotics to be continued via PICC (peripheral inserted central catheter) line, Malnutrition with high protein/calorie diet, and Alcoholism with vitamin deficiency. Pt. #9's Nursing Care Plan did not address the patient's diagnoses related to IV antibiotics, dietary needs and alcohol abuse. Confirmed during interview with CNO D at the time of review on 08/07/2024 at 10:40 AM.

A review of Patient #10's medical record, revealed: A 17-year-old female that is a current inpatient, was admitted on 05/30/2024 for Acute on Chronic Hypoxic Respiratory Failure. Past medical history included: Trach dependent, Seizures and PEG placed for tube feedings. Pt. #10's Nursing Care Plan did not address the patient's diagnoses related to Tracheostomy, Seizures and tube feedings. Confirmed during interview with CNO D at the time of review on 08/07/2024 at 11:05 AM.