HospitalInspections.org

Based on observation, interview, record review and policy review, the facility failed to ensure nursing care plans were developed for the individual needs of five patients (#3, #4, #11, #13 and #15) of eight nursing care plans reviewed. The facility's failure of not planning nursing care based on the assessed individual needs of patients had the potential to affect the provision of safe patient care by all staff and the health outcomes for all patients. The facility census was 28.
Findings included:
1. Record review of the facility's policy titled, "Assessment (Admission and Daily)" revised 03/15/12, showed direction for facility nursing staff (Chief Nurse Executive,CNE; Registered Nurses, RNs; and/or Licensed Practical Nurses, LPNs) to conduct initial and ongoing patient assessments and analyze the findings for the development of individual nursing diagnosis, goals of care, nursing interventions and implementation. Specific direction showed initial and ongoing assessments required nursing documentation of actual and potential problems and needs on the Master Treatment Plan at the time the medical or nursing diagnosis was made.

Record review of the facility's policy titled, "Axis III (a diagnosed physical condition effecting the development, continuance, or exacerbation of a mental health condition) Treatment Planning" revised 08/11, showed the following direction:
- All patients shall be assessed for medical conditions during the Admission Nursing Assessment and as needed throughout the hospitalization.
- All patients who demonstrate an active medical or nursing diagnosis shall have an appropriate Individual Problem Plan completed at the time the medical or nursing diagnosis was made.
- An Axis III Individual Problem Plan shall be added to the Master Treatment Plan and shall include the identified problem, goals for care and specific nursing interventions with their frequency.
- Nursing documentation in the treatment plan, related to the stated problem(s), shall be ongoing but no less than daily.

Record review of the facility's policy titled, "Reporting a Change in Patient Condition" revised 02/12, showed direction for facility nursing staff to document changes in the patient's condition and treatment modifications in the Master Treatment Plan. Specific direction for documentation of defined interventions, and time frame for reassessment and methods for measurement of outcome.

2. Record review of the facility's undated documents titled "Individual Problem Plan" (templates of nursing goals and interventions for specific nursing diagnosis and medical problems) showed:
- Individual Problem Plan for Infection (contained wound care interventions);
- Individual Problem Plan for Diabetes;
- Individual Problem Plan for Pain.

3. Observation on 11/13/13 at approximately 3:30 PM in the Adolescent Unit showed Staff T, RN assigned to care of Patient #13, examined the right hand and knuckles of Patient #13. The knuckles of the middle finger and ring finger had open circular wounds approximately 0.5 to one inch in diameter, redness and visible swollen skin extending approximately two inches beyond the wounds. Patient #13 voiced complaints of pain when examined by Staff T.

4. During an interview on 11/13/13 at approximately 3:00 PM, Staff R, RN assigned to care for Patient #13, stated that:
- The patient had a diagnosis of Insulin Dependent Diabetes Mellitus Type 1 (IDDM, the inability to produce the hormone insulin which was essential for turning food (sugar) into energy).
- He had a history of self injurious (causing intentional injury to oneself) behaviors.
- At the time of admission to the facility, he had knuckle wounds from punching walls and chest wounds from scratching himself.
- Nursing staff administered insulin injections and tested his blood sugar twice a day.

5. During an interview on 11/13/13 at 3:30 PM, Staff W, Medical Doctor (MD) stated that the patient had been diagnosed with IDDM for approximately three years and needed ongoing assessment of his IDDM and needed to be monitored closely while hospitalized in the facility.

6. Record review for Patient #13 showed:
- The patient was admitted on 10/29/13.
- A medical diagnosis of IDDM and physician orders for insulin injections and blood sugar testing two times daily.
- A physician physical examination conducted on 10/29/13 included assessment of bruising and wounds on the right hand and knuckles.
- The initial nursing assessment noted the IDDM medical diagnosis and a small scab on the right hand and a scratched chest.

The record contained no documentation of the development of nursing care planning for IDDM, wounds or pain.

7. Record review of Patient #13's daily/shift Nursing Assessment/Observation flow sheet(s) beginning 11/12/13 at 7:00 AM through 11/13/13 at 3:00 PM showed no nursing assessment of the hand bruising, wounds or pain.

8. Record review for Patient #3's medical record showed:
- The patient was 12 years old and admitted on 09/24/13.
- The initial nursing assessment included documentation of the medical diagnosis of Encopresis (the voluntary or involuntary passage of stools in toilet trained children greater than the age of four years old with constipation often a problem).
- The physician history and physical documentation of an Axis III diagnosis of Encopresis and Constipation and the patient was on a bowel program prior to admission to the facility.
- The assessment contained no specific diet or nutritional needs or problems requiring a dietary assessment.

The record contained no documentation of a nursing care treatment plan for Encopresis.

9. During an interview on 11/13/13 at approximately 2:45 PM, Staff R stated Patient #3 had Encopresis (the voluntary or involuntary passage of stools in toilet trained children greater than the age of four years old; constipation was often a problem). Staff R stated that the only intervention for the Encopresis was that he had to clean the feces off himself and wash his own clothes after he soiled them.

10. During an interview on 11/13/13 at approximately 2:30 PM, Staff Q, Psychiatric Tech Supervisor for the Adolescent Unit day shift, assigned to care for Patient #3, stated the "staff tried to catch him (Patient #3) before he went in his pants" and "tried to get him to go on the toilet but it didn't work".

11. During an interview on 11/14/13 at about 10:00 AM, Staff H, CNE, stated that staff did not develop care plans for Encopresis because interventions can be psychologically harmful and traumatize the patient. Staff H stated that there were nursing interventions that could have been done for patients who had Encopresis.

12. Record review of Patient #3's daily shift Nursing Assessment/Observation flow sheet(s) beginning 11/12/13 at 7:00 AM through 11/13/13 at 2:40 PM showed no nursing assessment of bowel movements.

13. Record review of Patient #4's medical record showed:
- The patient approached the physician and reported a painful skin lesion on her lateral left leg.
- The lesion was the second lesion reported since the beginning of the current hospital stay.
- Physician examination on 11/06/13 showed "a round, about 2" (inches) wide, mildly swollen/raised, erythematous (redness of the skin, often a sign of inflammation or infection) and warm lesion, with a central sting mark.
- Physician order for triple antibiotic ointment (TAO) to be applied three times daily, warm compresses to leg pain and oral antibiotics.
- A progress note by Staff H, CNE dated 11/07/13 of wound measuring six inches in diameter (a four inch increase in one day).
- Physician order for Keflex (an oral antibiotic medication to treat bacterial infections) 500 mg (milligrams=unit of measure) to be administered twice a day for two weeks.

No nursing documentation was found related to the identification of the wound through assessment and no nursing care plan for the wound.

14. During an interview on 11/13/13 at approximately 2:30 PM, Staff T, RN assigned to the care of Patient #4, stated that the patient had Cellulitis (an infection of the skin and deep underlying tissues that causes pain, and can be serious) on her left shin and received antibiotics for the infection. Staff T stated that Patient #4 had a wound that had gotten big quickly and had gotten better with antibiotic ointment, warm compresses and antibiotics.

15. Record review of Patient #4's daily shift Nursing Assessment/Observation flow sheet(s) beginning 11/12/13 at 7:00 AM through 2:45 PM 11/13/13 showed no nursing assessment or interventions for the wound.

16. Record review of Patient #11's medical record showed:
- The patient complained of ear pain on 11/08/13 and was diagnosed with serous otitis (fluid in the middle ear) and suspected mastoiditis (bacterial infection of the bone behind the ear).
- The physician prescribed an antibiotic and pain-relieving ear drops.
- The interdisciplinary treatment plan was not updated to include nursing assessments, nursing interventions, or outcome goals related to infection and pain.

17. During an interview on 11/13/13 at approximately 9:30 AM, Staff N, RN, stated that the interventions for Patient #11's infection and pain were the prescribed medications.

18. Record review of Patient #15's medical record showed:
- The nursing progress note dated 11/12/13 included the patient's concern that she was exposed to a food to which she is allergic.
- The patient was medicated with a prescribed antihistamine (medication given for allergic reaction).
- The interdisciplinary treatment plan did not include nursing assessments, nursing interventions, or outcome goals related to allergy.

19. During an interview on 11/13/13 at approximately 10:00 AM, Staff P, RN, stated that Patient #15's allergy could result in an anaphylactic (life-threatening) reaction. She stated that the interventions for Patient #15's allergy were the medications prescribed for such a reaction.

20. During an interview on 11/14/13 at 10:30 AM, Staff H, CNE, stated that:
- The daily shift Nursing Assessment/Observation Flowsheets did not include areas for documentation of the nursing assessment and interventions related to medical diagnosis and nursing problems.
- Nurses do not develop treatment plans and cannot enter them into the medical record.
- All treatment plans were developed by the Treatment Care Coordinator (TCC) after gathering information from the patient records.
- The nurses had previously developed Individual Problem Plans (care plans) until it was decided by the organization not to include them in the electronic medical record.
- Nursing staff used to staple them to the patient's paper record but they were torn off and discarded and considered not necessary.

21. During an interview on 11/14/13 at 10:45 AM, Staff A, Chief Operating Officer (COO), stated that she was aware of the limitations the nursing staff had adding information to the electronic medical record and that the system was not designed to include the nursing treatment plans.




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