HospitalInspections.org

Based on document review and interview, the facility failed to ensure the nursing staff followed the policy and procedure related to developing and updating the patients plan of care (POC) for one (1) of two (2) open patient medical records (MR's) (Patient # 1), and two (2) of the eight (8) patient closed MR's reviewed. (Patient # 3 & Patient # 10)

Findings include:

1. Review of the hospital policy titled, "Assessment/Reassessment/Care Planning", effective date 10/25/2010, indicated that the admission assessment data were reviewed prior to/and at the time of admission, to insure that key elements of prior hospitalization are known. Reassessment of the "patient is required to understand if the current plan of care is appropriate and effective". Reassessments are on-going and can take various forms such as following an episodic event. The POC "is updated when the patient's condition changes". The POC "is discussed collaboratively" as frequently as needed, "but at least every week with all service representatives" during interdisciplinary rounds. This policy was last reviewed on 03/07/2017.

2. Review of the hospital policy titled, "Patient Care Assignment", effective date 10/25/2010, indicated that the registered nurse (RN) "is responsible for oversight of all patient care related activities on a designated shift". This policy was last reviewed on 04/28/2017.

3. Review of the hospital policy titled, "Patient Safety Plan (Fall Risk)", effective date 10/25/2010, indicated that basic safety considerations were for all patients. All patients are assessed for safety/fall risk on admission and reassessed daily throughout the hospitalization, and documented. An "evidence-based (Morse fall risk assessment tool (which includes a fall risk score) is used to identify patients at increased risk for falls". It determines fall risk factors and targets interventions to reduce overall risks. This policy was last reviewed on 01/15/2018.

4. Review of the annual core competency for RN's, indicated to update the plan of care weekly and as needed and review each shift.

5. Review of the "Organizational Plan for Delivery of Patient Care, Treatment, and Services", standards of patient care indicated each patient has a plan of care. An interdisciplinary approach is utilized, as appropriate "to promote continuity of care".

6. Review of open MR for patient # 1 indicated the following:
A. The patient was a 74 y/o (year/old) admitted to LT # 1 (Long Term Care) hospital on 02/16/2018 with the following diagnoses: craniotomy, anorexia, cerebral abscess, mastoiditis, encephalopathy, recurrent cancer of the jaw and ear. The patient presented for postsurgical care which would include long term antibiotic therapy as well as dressing changes.
B. The initial PRE-ADMISSION ASSESSMENT form updated on 02/16/2018 at 10:35 am, indicated the treatment plan for the patient was to be a fall precaution.
C. On 02/17/2018 at approximately 7:56 pm the incident report indicated, the patient had fallen from the wheelchair. The patient's shift assessment flowsheet indicated the Morse Score was 30.0 (medium risk for a fall).
D. On 02/27/2018 at approximately 9:50 am the care conference documentation indicated, the patient had safety issues. The patient was a fall risk with alteration in mobility.
E. On 02/27/2018 at approximately 3:12 pm the incident report indicated, the patient was found sitting on the floor. The type of fall was an "anticipated physiological fall due to known risk factors". The patient's shift assessment flowsheet indicated the Morse Score was 85.0 (high risk for a fall).
F. On 03/02/2018 at approximately 8:32 pm the incident report indicated, the patient was sitting in the wheelchair, at the nurses station, and attempted to get up without assistance. A staff member was able to grab the patient before the patient fell. The type of fall was "unanticipated physiological fall due to unpredictable factors". The patient's shift assessment flowsheet indicated the Morse Score was 85.0 (high risk for a fall).
G. MR lacked any documentation that the patient had any POC for safety and/or fall risk.

7. Review of closed MR for patient # 3 indicated the following:
A. The patient was a 67 y/o admitted to LT # 1 hospital on 02/01/2018 with the following diagnoses: Pneumonia, congestive heart failure (CHF),
B. On 02/16/2018 at approximately 1:40 pm the patient care notes indicated the patient had fallen while attempting to use the washroom. The patient's shift assessment flowsheet indicated the Morse Score was 45.0 (high risk for a fall).
C. On 02/26/2018 at approximately 4:00 am the patient care notes indicated the patient was found in the room sitting on the floor. The patient's shift assessment flowsheet indicated the Morse Score was 70.0 (high risk for a fall).
D. MR lacked any documentation that the patient had an updated POC for safety/fall risk after either fall.

8. Review of closed MR for patient # 10 indicated the following:
A. The patient was a 64 y/o admitted to LT # 1 hospital on 12/03/2017 with the following diagnoses: respiratory failure and CHF.
B. The initial PRE-ADMISSION ASSESSMENT form indicated the treatment plan for the patient was to be a fall precaution.
C. On 01/05/2018 the patient care notes indicated the patient had fallen. The patient's shift assessment flowsheet indicated the Morse Score was 45.0 (high risk for a fall).
D. MR lacked any documentation that the patient had an updated POC for safety/fall risk after the fall.

9. On 03/15/2018 at approximately 12:05 pm with administrative staff member A # 3 (Chief Clinical Officer-CCO), confirmed that the above patient's MR's were lacking documentation related to their POC. Patient # 1 did not have a POC for safety and/or falls. Patient # 3's and Patient # 10's MR POC was not updated after their falls.

Based on document review and interview, the facility failed to ensure the patient's medical record (MR) was accurately written and promptly completed for two (2) of eight (8) closed patient MR's reviewed. (Patient # 3 & Patient # 7)

Findings include:

1. On 03/15/2018 at approximately 10:30 am with administrative staff member A # 3 (Chief Clinical Officer-CCO), the MR for patient # 3 was reviewed. The MR lacked discharge instruction documentation. The patient was discharged from LT # 1 (Long Term Care) hospital on 03/02/2018.

2. On 03/15/2018 at approximately 10:35 am with administrative staff member A # 3, the MR for patient # 7 was reviewed. The MR lacked discharge instruction documentation. The patient was discharged from LT # 1 hospital on 01/29/2018.

3. Interview on 03/15/2018 at approximately 10:45 am with administrative staff member A # 3, confirmed the above patients MR's were lacking discharge instruction documentation.