HospitalInspections.org

Based on policy and procedure review, patient medical record review, and staff interview, the nursing executive failed to implement the policy related to admission assessments for 3 of 6 patient records reviewed. (pts. N1, N5 and N6)

Findings:
1. at 1:50 PM on 9/28/11, review of the policy and procedure "Patient Admission", indicated in section V. "Policy Statements", "...B. All adult patients admitted to the hospital will have a Nursing History and Screen initiated and completed within 8 hours of admission...C. The initial physical assessment is to be completed by a RN...It must be completed within 8 hours..."

2. review of patient medical records through out the survey process of 9/27/11 and 9/28/11 indicated:
a. pt. N1 was admitted on 12/15/10 and died on 12/24/10 and had a form titled "Interdisciplinary Plan of Care & Communication" with a number (bottom left side of page) as GU007a through GU007h--(four pages double sided) that was blank on all four pages
b. pt. N5 was admitted on 6/3/11 and had a form titled "Interdisciplinary Plan of Care & Communication" that was completed by nursing on 6/8/11
c. pt. N6 was admitted 11/10/10 and was lacking the form titled "Interdisciplinary Plan of Care & Communication"

3. interview with staff member NH at 1:40 PM on 9/28/11 indicated:
a. the "Interdisciplinary Plan of Care & Communication" form is the nursing assessment form to be completed at the time of admission
b. pt. N1 had a blank four page form (double sided) in the medical record for a nursing admission history and physical (as noted in 3. a. above)
c. pt. N5 did not have the nursing admission history/assessment form completed for 5 days
d. pt. N6 was lacking a nursing admission history/assessment form

Based on policy and procedure review, patient medical record review, and staff interview, the nursing executive failed to implement the policy related to the creation of a nursing care plan for 3 of 6 patient records reviewed. (pts. N1, N5 and N6)

Findings:
1. at 1:55 PM on 9/28/11, review of the policy and procedure "Plan of Care", indicated in section VI. "Procedures",: "A. Upon admission, the Registered Nurse will develop the plan of care including all of the applicable issues: 1. Safety. 2. Infection Control..."

2. review of patient medical records through out the survey process of 9/27/11 and 9/28/11 indicated:
a. pt. N1 was admitted on 12/15/10 and died on 12/24/10 and had a form titled "Interdisciplinary Plan of Care & Communication" with a number (bottom left side of page) as GU007a through GU007h--(four pages double sided) that was blank on all four pages indicating no nursing care plan was developed
b. pt. N5 was admitted on 6/3/11 and had two weekly "Interdisciplinary Rounds" documents indicating the nursing care plan was reviewed by various disciplines, but was lacking any participation/documentation on these by nursing staff
c. pt. N6 was admitted 11/10/10 and was lacking the form titled "Interdisciplinary Plan of Care & Communication" and lacking any documentation that a nursing care plan was initiated

3. interview with staff member NH at 1:40 PM on 9/28/11 indicated:
a. the "Interdisciplinary Plan of Care & Communication" form is the nursing assessment form to be completed at the time of admission and also acts as the nursing care plan
b. pt. N1 had a blank four page form indicating that a nursing care plan was not initiated
c. pt. N5 had a nursing care plan initiated 5 days after admission (admitted 6/3/11 with form completed 6/8/11) and was lacking nursing involvement in weekly interdisciplinary care planning conferences
d. pt. N6 was lacking the initiation of a nursing plan of care after admission on 11/10/10

Based on patient medical record review and staff interview, the facility failed to ensure the completion of code blue forms for 3 of 3 patients who were involved in code blue events. (Pts. N1, N2 and N4)

Findings:
1. review of patient medical records through out the survey process of 9/27/11 and 9/28/11 indicated:
a. pt. N1 had a "Cardiopulmonary Resuscitation Record" form that is lacking the signatures of the registered nurse and the respiratory therapist who attended and participated in this patient's code of 12/24/10
b. pt. N2 had a "Cardiopulmonary Resuscitation Record" form that is lacking the signature of the respiratory therapist who attended and participated in this patient's code of 7/31/11
c. pt. N4 had a "Cardiopulmonary Resuscitation Record" form that is lacking the signature of the physician who attended and participated in this patient's code of 5/15/11

2. interview with staff member NH at 1:40 PM on 9/28/11 indicated:
a. it is unclear who all of the participants of a code are as the form only requests a signature of one RN, one respiratory therapist, and the physician involved in a code event
b. the medical records listed in 1. above are all lacking at least one signature on the "Cardiopulmonary Resuscitation Record" form