HospitalInspections.org

Based on medical record review, staff interview and policy review it was determined the the facility failed to ensure the Interdisciplinary Plan of Care was individualized based on the assessment and/or needs of the patient. This affected one (Patient #8) of ten medical records reviewed. This active census was 61.


Findings include:


Review of the Nursing Plan of Care Policy NR.1440 (reviewed 11/2015) states that each patient admitted will have an Interdisciplinary Plan of Care developed, which will be based on his/her assessed individual needs. Appropriate interventions will be recorded on the plan of care. A weekly update of the patient's status and development of new short term goals will be accomplished through the involvement of the interdisciplinary team. Appropriate disciplines will complete the status update columns prior to the team conference.



1. Review of the medical record for Patient #8 revealed an admission date of 06/07/16 for a traumatic brain injury secondary to a motor vehicle accident. Review of the physician's orders and the restraint log confirmed from 06/08/16 at 2:18 AM through 06/15/16 at 9:30 AM and from 06/18/16 at 7:29 AM through 06/20/16 at 4:11 PM the patient had a bed enclosure and a pelvic restraint in place.

Review of the updated interdisciplinary plan of care dated 06/14/16 and 06/20/16 failed to include the restraints and/or interventions.

This finding was confirmed with Staff F on 07/13/16 at 12:29 PM.

Based on medical record review, staff interview and policy review it was determined the facility failed to ensure that patients in restraints were monitored every two hours per facility policy. This affected three of ten medical records reviewed. (Patient's #7, #8 and #9) The active census was 61.

Findings include:

Review of the Use of Restraints in Non Psychiatric Hospital or Unit Policy NR.3620 ( reviewed 11/2015) states for non violent restraints nursing should monitor every two hours through observation, interaction, or direct examination. Monitoring is to include level of distress/agitation, mental status, cognitive function, vital signs as appropriate, hydration, nutrition, elimination needs, positioning changes/range of motion and circulation and skin checks.

1. Review of the medical record for Patient #7 revealed the patient was admitted on 06/21/16 following a cerebrovascular accident on 06/21/16. Review of the physician's orders and restraint log confirmed the patient had a bed enclosure and a pelvic restraint from 06/22/16 at 10:33 AM through 06/29/16 at 10:08 AM.

Review of the restraint flow sheets for the specified time frame lacked documented evidence nursing staff monitored every two hours per facility policy.

This finding was confirmed with Staff F on 07/13/16 at 2:12 PM.


2. Review of the medical record for Patient #8 revealed the patient was admitted on 06/07/16 due to a traumatic brain injury secondary to a motor vehicle accident. Review of physician's orders and the restraint log confirmed from 06/08/16 at 2:18 AM through 06/15/16 at 9:30 AM and from 06/18/16 at 7:29 AM through 06/20/16 at 4:11 PM the patient had a bed enclosure and a pelvic restraint in place.

Review of the restraint flow sheets for the specified time frame lacked documented evidence nursing staff monitored every two hours per facility policy.

This finding was confirmed with Staff F on 07/13/16 at 2:42 PM.


3. Review of the medical record for Patient #9 revealed the patient was admitted on 06/08/16 due to a traumatic brain injury. Review of physician's orders and the restraint log confirmed from 06/08/16 at 5:16 PM through 06/09/16 at 10:55 AM the patient had a bed enclosure and a pelvic restraint in place.

Review of the restraint flow sheets for the specified time frame lacked documented evidence nursing staff monitored every two hours per facility policy.

This finding was confirmed with Staff F on 07/13/16 at 2:52 PM.

Based on medical record review, staff interview and policy review it was determined the facility failed to ensure the Interdisciplinary Plan of Care was individualized based on the assessment and/or needs of the patient. This affected three of ten medical records reviewed. (Patient's #2, #8 and #10) This active census was 61.

Findings include:

Review of the Nursing Plan of Care Policy NR.1440 (reviewed 11/2015) states that each patient admitted will have an Interdisciplinary Plan of Care developed, which will be based on his/her assessed individual needs. Appropriate interventions will be recorded on the plan of care. A weekly update of the patient's status and development of new short term goals will be accomplished through the involvement of the interdisciplinary team. Appropriate disciplines will complete the status update columns prior to the team conference.


1. Review of the medical record for Patient #2 revealed an admission date of 06/21/16 following surgical excision of an infected umbilical cyst. Physician documentation described the wound measurement as an opening to the middle that was 7 mm deep, 15 mm wide and 200 mm long.

Review of the nursing plan of care addressed skin integrity, however, failed to include interventions related to the patient's assessment and diagnoses.

This finding was confirmed with Staff F on 07/13/16 at 1:13 PM.


2. Review of the medical record for Patient #8 revealed an admission date of 06/07/16 for a traumatic brain injury secondary to a motor vehicle accident. Review of physician's orders and the restraint log confirmed from 06/08/16 at 2:18 AM through 06/15/16 at 9:30 AM and from 06/18/16 at 7:29 AM through 06/20/16 at 4:11 PM the patient had a bed enclosure and a pelvic restraint in place.

Review of the updated interdisciplinary plan of care was reviewed for 06/14/16 and 06/20/16 failed to include the restraints and/or interventions.

This finding was confirmed with Staff F on 07/13/16 at 12:29 PM.


3. Review of the medical record for Patient #10 revealed an admission date of 06/29/16 following a subarachnoid hemorrhage. Review of the fall event log revealed the patient had a fall from the toilet/commode on 07/08/16. The interdisciplinary plan of care was reviewed by the team on 07/13/16.

Review of the interdisciplinary plan of care failed to include the patient was at risk for falls prior to or following the incident.

This finding was confirmed with Staff F on 07/13/16 at 2:32 PM.