HospitalInspections.org

Based on interviews and documentation review, it was determined the facility staff failed to keep current the nursing care plan and/or interdisciplinary plan of care for one (1) of three (3) patients (Patients #1).

The findings include:

On July 5, 2017 and July 6, 2017 the Plan of Care/Interdisciplinary Plan of Care for Patient #1 was reviewed.
There were no nursing notes to indicate any changes, updates, adjustments or evaluations for any of the twelve (12) problems listed below documented on the Plan of Care.

The identified problems and the responsible discipline are as follows:

1-Potential for seizure activity; Nursing - identified 12/31/16,
2-Respiratory (Altered respiratory function) related to Ventilation, Tracheostomy/endotracheal tube; Nursing and Respiratory Therapy- identified 12/31/16,
3-At risk for complications associated with feeding tube dislodgement; Nursing,
4-Potential for complications discomfort related to dx (diagnosis) of GERD (Gastroesophageal reflux disease); Nursing- identified 12/31/16,
5-Ineffective breathing patterns related aspiration...; Nursing and Respiratory Therapy- identified 12/31/16,
6-Ineffective airway clearance...; Nursing and Respiratory Therapy - identified 12/17/15,
7-At risk for social isolation and sensory deprivation; Recreational Therapy, Nursing, Respiratory Therapy, Social Work and Dietary - identified 11/22/16,
8-Ventilator dependent; Respiratory Therapy and Nursing - identified 11/30/16,
9-Nutritional needs 100% via tube feeding; Dietary and Nursing - identified 1/1/17,
10-Self care deficit related to neuromuscular impairment from neurological disease, sensory deficits; No discipline identified as responsible to evaluate - identified 3/15/17,
11-Discharge planning related to need for continued care in an alternate setting; Social Work - identified 6/21/17,
12-High risk injury and unplanned decannulation...; Nursing and Respiratory Therapy - identified 6/1/17.


On 7/6/13 Staff Member #7 was interviewed who stated, "Yes, that is the social work problem we identified." Staff Member #7 was asked when the parent began to express the desire to take Patient #1 home and Staff Member #7 stated, "He/She has always been asking when can she/he take (Name of Patient #1) home." Staff Member #7 was asked if there was any updated information in the computer that was not on the printed copy of the Plan of Care and stated, "No".